Maternal mortality in countries with voluntary health insurance or none

GROUP 2.-Maternal mortality in countries with compulsory health insuranc

United States decrease during periods of compulsory insurance in other countrie

FOR CHILE, FRANCE AND THE NETHERLANDS, THE FIGURES FOR COMPARISON

1 Comparison over comparable years of these countries can be made with the figures for these countraes shown in group No. 2.

Source: U. S. Bureau of the Census. J. Yerushalmy: Annals American Association of Political and Socia Science.

I should like to quote at this point Jacob Yerushalmy, Ph.D., principal statistician in the United States Public Health Service, Bethesda, Md., who said, as reported in "The Annals of the American Academy of Political and Social Science" Philadelphia, January 1945, "In consideration of future accomplishments in the field of maternal and infant hygiene, it is necessary to distinguish between countries whose present rates are high and those who have attained certain low evels. As to the former-and they constitute a majority of the countries-no reason can be advanced why they could not bring their rates down to the level of more fortunate countries. In the final analysis, it is merely a question of time. The countries now enjoying low rates were only several decades ago on the same high plane of infant and maternal mortality. Whether the time interval could be shortened is more a social economic than a medical problem. The reductions thus far attained are primarily from conditions and causes which are environmental in nature; consequently they result from general improvements in sanitary conditions and the elevation of the standard of living."

This supports the point which I make that we are making the greatest progress in the world in the reduction of maternal mortality under the procedure which the medical profession in this country is following, and therefore, the vast changes which are proposed by this bill not only are unnecessary to accomplish the objective of improved national health upon which we all agree, but that the present program might well be impeded or destroyed.

Comparisons with conditions in Britain are likely to furnish little support for the proponents of this bill and as an example of what I mean, I recall that Mrs. Marjorie D. Spikes, who is an attaché of the British Embassy at Washington, and who spoke on January 10, 1946, to the Service Bureau for Women's Organizations on "Britain's Postwar Plans for Children and the Home" at. Hartford in my State, said that Britain's greatest problem was revealed when the children of the slums were evacuated to the country to protect them from the bombing raids during the war. Mrs. Spikes said the squalor of these slum houses and their overcrowding was so grave that a health program was considered aseless until the housing problem could be solved.

Another item of testimony which surely does not offer much assurance that Compulsory health insurance in the countries where it has been tried for many years is hitting the mark is that by Dr. Percy Stokes, medical statistician of the Ministry of Health for Britain and Wales, speaking at the Sterling Hall of Medicine at Yale University, on February 20, 1946, on "The Future of Medical Statistics" when he said:

"As far as the magnitude of the health problem is concerned in relation to economic conditions, the incidence of sickness is evenly distributed among rich and poor alike. Once stricken, however, the fatality rate is much higher among

the poorer classes and is directly attributable to housing conditions and sanitation."

Have we a problem in maternal and infant care? Yes, a very definite one Regardless of our splendid record of the past 10 years, we can do better. There are certain areas in this country, mostly in the South, where maternal mortality rates are still high and indeed improvement in many Northern and Wester States is possible. But we are on the right track now, and I think we know how to reach our goal.

The medical profession wholeheartedly endorses the program of improvemen: in maternal and child health and the extension of the service to all mothers and children where payment for such services would be a hardship. The medica profession has repeatedly stressed the social economic factor in the whole prob lem of improved health.

Dr. SENSENICH. And also a statement from the Council on Medica Service and Public Relations of the American Medical Association relative to nonprofit prepayment medical service plans.

Some of those questions were asked me this morning.

The CHAIRMAN. Both statements may be carried in the record. (The document referred to is as follows:)

NONPROFIT PREPAYMENT MEDICAL SERVICE PLANS SPONSORED BY MEDICAL SOCIETTIS SUBMITTED BY COUNCIL ON MEDICAL SERVICE AND PUBLIC RELATIONS, AMERICAN MEDICAL ASSOCIATION

Payment for the costs of medical care by prepayment or budgeting throug voluntary medical society sponsored plans is rapidly expanding in areas of oper. tion, numbers of persons protected, in types of service provided, in popular & ceptance by the public and physicians.

The popular movement in this field began about 1940. The organizations plans beginning at about that time was the result of studies and small scale et periments which had been carried on by medical societies for some years—SILO 1925 in the State of Michigan, for example.

Attached hereto, marked "Exhibit A," is a chart reflecting the growth in nu: bers of plans organized and operating from 1939 to 1946. Also attached is chart marked "Exhibit B," reflecting the number of persons protected by s plans. Also attached is exhibit C, indicating the States in which plans are operating.

Such plans have utilized legal means of organization, depending on State statutory requirements. However, the basic principles and objectives have be almost identical. These are the provisions of certain specified services of pt; sicians in cases of illness or injury of catastrophic proportion as to cost at t lowest possible expense with the greatest possible return in benefits to the bes ficiary member consistent with sound financial practice.

Inherent in the operation of these plans is the principle of noninterferen with the patient's choice of legally qualified physician or hospital and noninte ference with the physician in his treatment of the patient.

Usually these plans are incorporated either under nonprofit statutes or und special enabling legislation, and sometimes under insurance statutes. Bet ciary members are provided with services or payment for services of qualifi>= physicians in accord with schedules of fees established by the medical profes sion in the area of operation of the plan.

In most plans complete service under the subscriber's contract is provided b the physician participating in the plan. Extra charges may be made under e tain specified conditions to beneficiary members whose incomes normally exre a moderate amount or who may demand and occupy luxury type of accommoda tions in the hospital. In any event, beneficiary members receive benefits equi... in cash value as credit against the physician's fee.

Accumulated experience in coverages such as offered by these plans has m possible a gradual expansion and extension of benefits. Early efforts were· ward complete medical care, including such services as physical examinations refractions, home and office calls, etc. No experience being available at that t (or at present in adequate volume) as to the possible utilization of such serv: -when available without penalty or imposed controls, there resulted errors rates or premiums and withdrawal of such comprehensive efforts. Experien

gained in these trials indicates costs of such magnitude, due to unrestrained utilization of benefits, as to make such programs unacceptable by the public.

Most plans now in operation have made beginnings with fairly restricted coverages such as services for surgical cases, obstetrical cases, X-rays, and anesthesia in hospitalized cases. Some have successfully initially offered care for hospitalized medical cases.

Almost without exception, plans that have been in operation for more than 2 or 3 years have been able to broaden benefits as experience has been gained to the, point where at least all services in cases so severe as to require hospitalization are now covered, as well as many of the more serious cases usually cared for in physicians' offices.

Availability of the protection of such plans to all persons becomes increasingly possible as experience is accumulated in enrollment and underwriting techniques. Originally offered in most cases only to employed or common-interest groups, present practice in older plans permits enrollment of individuals under methods developed through trial-and-error experiments steadily being broadened and expanded Also programs and methods have been utilized and are being expanded to make possible enrollment in rural areas of individuals and farm families with considerable success.

Arrangements have been made, and others are possible, to care for special categories and groups such as disabled war veterans and for care of indigents under local welfare boards, etc. Statutes under which many of these plans operate specifically provide for the making of contracts with various governmental and nongovernmental organizations and units for provision of care either on the basis of contribution (that is, subscription rate or premium payment), or a lump sum for all members of the group involved, or on the basis of costs plus a fixed fee. There is no category or type of service which cannot be provided under such arrangement through these voluntary plans.

While there are many such plans in operation with considerable variation in costs and benefits and enjoying varying degrees of success as to numbers of persons enrolled and financial experience, Michigan Medical Service, of Detroit, Mich., is indicative of what can be accomplished by these medical-society-sponsored plans. The following statements are based on filed official statements of Michigan Medical Service or can be confirmed at the home office of the company in Detroit, Mich.

Michigan Medical Service was authorized under a special enabling act, copy of which is attached hereto, by the insurance department of the State of Michigan and commenced business March 1, 1940.

Enrollment of beneficiary members in Michigan at December 31 of each year was as follows:

Payments to physicians for services to subscribers were as follows:

Percentage of income paid for administration by years since inception was as 'ollows:

Almost without exception these medical-society-sponsored plans provide bene fits to the dependents in the same manner and in the same amount as to contract holders. This is important in that experience in Michigan Medical Service indi cates that wives and children of contract holders receive service aggregating approximately 80 percent of all services provided, both as to the number of services and the costs therefor.

It is entirely possible that, in the course of the next few years, this type of prepaid medical care can be made available to all citizens of the State of Michigan who desire it at costs not to exceed the present cost to subscribers, and possibly lower. It will be seen by reference to the figures quoted above that there is a direct relationship between volume of beneficiary members covered and admir istrative expense, which can be reduced as volume increases.

Possibly additional benefits may be granted as experience in methods an: techniques is gained through operation, so that in the near future coverage may be extended to include all types of conditions of a catastrophic nature as t cost, as well as most conditions requiring more than the ordinary home and office calls of a physician. Such services as the home and office calls of physicians can be included in such a program, either voluntary or compulsory, only if cottrols are instituted to eliminate abusive utilization at the demand of the patient. Apparently S. 1606 recognizes this problem by attempting to outline methods of control which will guard against abuse in utilization of the physician services by imposing cash penalties on the patients. The imposition of cast penalties, such as part payment of each fee, or total payment for first calls, in ary illness would be ineffective in controlling such abuses unless penalties are s severe as to inhibit legitimate demands for medical care. The only alternative would be a compulsory examination of each individual patient to determine the necessity for medical care. Such examinations would be intolerable to both the physician and the patient.

One of the important considerations in regard to either a voluntary or cour pulsory program of health insurance is the attitude of physicians who are render ing the service to the contributors or subscribers. Real dissatisfaction results unless the program is simple in operation, effective in application to the patie and his relation to the physician. Statements have been made by proponents (? S. 1606 that red tape will be reduced to a minimum; that there will be no inter ference in the physician-patient relationship; that there will be considera savings in time and effort to the physician in that it will not be necessary for h to maintain patient accounts and collections.

If cash payments are imposed to control abuses on home and office services of physicians, the physician will, of necessity, maintain patient accounts and w be required to enforce collections of the cash payments. This would increase necessary accounts and collections since Government would be a third party: the situation. In fact, the percentage cost of collections would conceivably r due to the small amount per patient's call involved.

If abusive use of medical care is to be controlled by the necessity for justifica tion in the nature of documentary proof or otherwise, the physician is like? to become dissatisfied with the necessity for completing detailed forms, requis tions, and authorization. Examples of such red tape are the forms utilized present Government bureaus dealing with medical care-the Veterans' Admir's tration, the emergency maternity and infant care program, etc.-with which physicians have had experience.

The problems of extending coverage and controlling utilization within the financial framework of a compulsory health insurance program are identic.. with the problems under a voluntary program, except that the compulsory pla brings the Government as a third party into every arrangement.

Considerable experience has been had by the Michigan Medical Service in t) matter of abusive utilization without imposed controls in the operation of original complete medical care contract. Utilization of physicians' services ↑ home and office calls rose under this prepayment contract to approximately f and one-half times normal. It is impractical to look to the physician to enfer voluntary controls, as any attempt on his part results in ill will toward him the part of the patient who has demanded service. Patients demanded atten".