Chapter Fifteen. Some Social Aspects of Medical Socialism

C HAP T E R FIFTEEN Some Social Aspects of Medical Socialism T 18TH proudly called it self the Century of Reason. The 19th boasted of being the Century of Progress. In the same fashion, the 20th deserves one of two titles: the Century of Marxian Totalitarianism or of Bis marckian Social Security. That the two movements, for gov ernmentalizing the security of the individual and toward unrestrained absolutism, coincide is far from accidental. Both have the same deep psychological root: the longing in the heart of the masses, on which the politician can capitalize, for protection against the hazards of life, cost what the protection may. And both imply vast controls by the State to replace the responsibility of the individual. 1 Both belong in the same chap ter of the history book: The Welfare (Police) State. Short of having reached total power, the Welfare State, like any other, has to win the mass loyalty on which Power de pends. Spending one way and taxing the other is the age-old formula. Both have to be supported by arguments.

HUMANITARIANISM Until after the tur~ of. th~ century,. the AND PATERNALISM appeal to humanitariamsm prOVIded the Number One argument for governmentalized medicine. Poor people cannot afford to take care of their own health. To leave them to charity, public or private and both were highly developed long before Bismarck-would be "humiliating." Why, the poor may be so proud that they might not take the alms and would rather suffer or even die, so . the argument implied. Then, there are the semi-poor who 134 135 ] SOME SOCIAL ASPECTS OF MEDICAL SOCIALISM could get along normally, but who might be wrecked by major sicknessin the family. Mter World War I, more rationalization was needed to justify the .horizontal expansion of the schemes to ever higher income brackets. It easily was·found in the Bismarckian ar mory of ideas: people must be insured against sickness in a compulsoryfashionbecausetheydo nottakecareof themselves.

They do·not know how to use their money rationally; the.gov emment has to step in and teach·them to make sound use of their incomes. The paternalistic. image. supplements the hu manitarian vistas. The implication is that people "lack the insight and the moral strength to provide spontaneously for their own future. But·then it is not easy to silence the voices of those who .ask whether it is not paradoxical to .entrust the nation's welfare to the decisions of voters whom the law itself considersincapable of managing their own affairs; whether it is not absurd to make those people supreme in the conduct of gov ernment -who are manifestly in need of a guardian to prevent them from spending their own income foolishly. Is it reason able to assign to wards the right to elect their guardians?"2 Also, substituting by authority for the private propensity to save tends to undermine the saving habit which it is supposed to.inculcate and to supplement.

Note in passing that the most effective argument for com pulsory medicine· still is:· to provide for people in the low in come brackets who cannot provide for themselves. But. in practice, and from the outset,. the. schemes always include a majority of members who could very ·well taKe care of them selves. And almost always they leave out a minority, especially the lowest income group, that still has to fall back on poor relief or private charity. AUTHORITARIANS Wor}d War II has ope~ed ~ new ide TURNING· RED ologlcal era. The question IS not only of being ·humanitarian or of teaching people ·how to spend· properly. The question is to provide security for all, and to do so in .such a fashion .as to equalize the hazards oilife between rich and poor,betweenhigh-sal aried and low-paid, between skilled and unskilled, etc. E.quali tarian security is the new goal-. the professed goal, anyway.

COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 136 He who wishes to urtderstand the trends of Europe in, the face of the soul-searching effects of World War II must visu alize this underlying equalitarian trend. It permeates politics and economics. It is expressed in communist and socialist strength. Equalitarian ideas often blend even with those of parties and movements of a conserVative character, to say nothing of those of "fascist" leanings. PROFESSIONS Equalitariani~m is a psychological power LOSING STATUS of first ~agmtude that creates a ne~ O?tlook on hfe. In Europe, even on thIS SIde of the Iron Curtain, it has become' almost a part of many people's mental make-up. One of its most spectacular, and from the cultural point of view most significant, manifestations is the pressure to deflate the white-collar middle class and upper-middle class type of society, with its conventional values, its comparative leisure, and its cultural interests. In Britain, in particular, the outspoken sentiment of the masses and the politi cal and administrative weapons in the hands of their repre sentatives are being used to depreciate the position of the professions. Why should anyone be better off than a mechanic or lead a life different from his? What that means, why the professional is in need of higher income and more leisure' than the artisan, has been succinctly formulated by an English economist: 3 "High-grade intellectual work .... demands a measure of freedom from incessant preoccupation with penny saving; the half-hour in the rain at the bus-stop, the long wait to borrow the book which one cannot afford to buy, the odd jobs and make-do-and-mend which nibble away time and energy. These things are not necessarily more unpleasant to the professional than to the artisan . . .

but they affect his work as they do not affect the arti san's." "It demands, more positively, opportunity; the relaxation in which, deep in the apparently idle mind, ideas meet and cross-fertilize and mature; the stimulus of informal, as well as professional meetings with col leagues and ... others concerned with a widely different expertise, at home and abroad; the leisure and means with which to balance the claims of specialty with a sav ing leaven of civilization. All these are expensive."

137 ] SOIrtE SOCIAL ASPECTS OF· MEDICAL· SOCIALISM The medical.profession is perhaps most sensitive among all groups .of the "intelligentsia" to the· effects .of this.· leveling process. ' In the medical field, study is longer and more ex pensive, the earning life period shorter,and the investment in technical installations more ·costly than in any other "aca demic" activity. Indeed, its contribution to the civilization and progress of humanity rests.on a material· foundation. To deny the latter is tantamount to stultifying the former. Such a policy may fit into the Garrison State of the Soviets, in which civilization is identical with military preparedness, and prog ress with regimentation. INTRA ..PROFESSIONAL "You know, Lo~d ~order, as I do, EQUALITARIANISM that onedo.ctor IS as.good as another .. doctor," saId Aneurm Bevan to the spokesman of the British profession. The tendency of authoti tarian medicine to level the differences within the profession may be· even more significant, .perhaps, than the tendency to level the· profession as a whole. The second pressure could be corrected by raising the doctors' honoraria-if that were finan cially possible and politically expedient. But the first is inherent in the very nature of the system. How should ·the bureaucracy distinguish between· one surgeon and another in terms of re spective ability? It has to pay both on the basis of well-defined, uniform standards, lest purely arbitrary judgments and corrup tion should prevail.

The effect on medical practice would be similar to that on a business which had ceased to distinguish between the ship ping clerk and the executive vice-president, except in terms of seniority and stop-watch records. Continental panel·systems mitigate the devastating ill effects by leaving a substantial sphere of the medical business in freedom. Doctors fortunate enough to retain or to develop a private practice can afford to devote part of their time to the "mechanized" panel practice, while still having sufficient leisure left to develop their art. Where medical security is newly introduced, the profession lives for years on its accumulated capital, so to speak, of past expe rience and accomplishment. What will happen when private practice fades out, together with the old generation of doctors who grew up in it? So will the beneficial results of private practice on the medical art··itself. .

COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 138 The new generation of doctors whose future lies in the com pulsory system does not even need the training the old used to acquire. Characteristically, from England comes the sugges tion that, in view of the urgent demand for more doctors to relieve the shortage caused by the onrush of non-paying patients, the rank and file of young doctors should be permitted to pass with a training less comprehensive than required at present. According to Dr. J. Plesch, London, a four-year voca tional course would do, while future consultants, specialists, and scientists should be the only ones to receive a full-fledged aca demic and clinical training. Lancet, the pro-Bevan (!) British medical journal, commented caustically (April 2, 1949):1 "Retrograde as this proposal may seem, it is none the less in line with the present tendency of the over-burdened general practitioner to disuse his medical skills and practice medicine on a level little above that of a competent orderly. If we are going to be content with conditions under which real medicine is to be practiced almost exclusively at or from hospitals, why not frankly acknowledge the fact and accept Dr. Plesch's pro posal to train our students accordingly?" A second-class train ing for scheme practitioners should be in accordance. with the second-classmedical service they tend to supply in most scheme frameworks.

SOCIALIST PURPOSE The socialistic implications of compul OF "SECURITY" sory medicine, especially in the health security systemsof France and Britain, to say nothing of Soviet Russia, have far greater significance than the .leveling trend that affects the doctors. The idea underlying those security systems has been clearly formulated by their leading French representative. According to Monsieur Laroque, "The French social. security plan was aimed in essence at no other target than to introduce a little more justice into the distribution of the national income." In other words, and this holds for the British approach as well, not health care per se is the prime objective. "Security of the power to work" is incidental only, or so it appears, to the goal of correcting inequalities and injustices in the capitalistic pat tern of income distribution. Health care turns out to be one of the pipelines through which the re-canalization of wealth is to be accomplished. It is, to repeat, "distribution, by author139] SOME SOCIAL ASPECTS OF . MEt>ICAL SOCIALISM ity,of part of the national income."4Andthemaster mind .whose industry and political efficacywere responsible for put tingoverthenew scheme in France does not hesitate to draw the logical conclusion: a high wage country like the United States.needs no compulsory medicine, as·doesa low wage coun try like France.

Assuming that the income pattern· needs correction: do health schemeshelp or at least do they contribute.to that goal? It takes economic illiteracy to overlookthe fact that their cost, if··shiftedonto business,are most likely to be added·to the price of the product which those people buy whose income is sup posed to be hiked. As a class, the beneficiaries receive at best with the left hand what they lose with the right.. Inasmuch as they carry the cost themselves, as they do to an appreciable extent even in France, it .obviously comes out ·of their own pockets. Even nominal wages tend to be directly affected. It is widely understood that the benefits of social security in general, and of health security in particular, are substitutes for higher wages. A redistribution still does take place, indeed, but not ·somuch between labor and capital as rather among the "beneficiaries" themselves. The young, the healthy, the productive workers have to contribute but may get little or nothing out of the sick ness schemes.. The sick, the hypochondriac, the unproductive may get much more than they put in themselves or what .their share would be in terms of marketwise remuneration forserv ices rendered. Thus, the national incomepattemis being reshuffled in. the direction of reducing the incentive for pro ductivity. Together with a system of subsidies perchild,a system which is part and parcel.of social security in Russia ·as well as in Britain and France, the negative incentive. already has reached such proportions that in France, at any rate,special measures had to be taken to stem the inclination of family heads to "retire" on steady family allowances (plus occasional sick ness benefits).

Such and similar disincentives account in part fora daily absenteeism among British coal miners· which lingers at ·this writing in the neighborhood of 14 per cent of the manpower, this in· spite of all official "pep-talks" .to boost the working morale. The effect on production costsis enhanced·by the fact COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 140 that the most productive workers-the healthiest-consider their contributions to the sickness scheme as an unjustified head-tax. They try to shift it by clamoring for· higher wages. THE SECURITY CART In. ~urope, medical bene~ts are ~he BEFORE THE orlgm and core of all s~clal securIty. ECONOMIC HORSE There!ore,. the. ec~noffilc, fiscal and financIal unphcatlons of the one scarcely can be discussed lest the discussion encompass the whole.field. The effects of health "security" on the level and structure of wages, on labor mobility (or immobility) and pro ductivity, on production costs and commodity prices, on the saving propensity of the public and its economic "morale" in general-would have to be analyzed in conjunction with old age pensions, fanilly allowances, unemployment insurance, etc.

Nor should such "direct" social subsidies as for education and housing be left out of the picture. For all of them it is logical, as expressed by the clear-sighted Canadian economist, Gilbert Jackson, "that a point must at some stage be reached when (for example). the marginal tooth extraction must be balanced off and weighed against the marginal ticket to the rugby game." In other words, the national income has to pay for everything the nation consumes-unless it lives on its capital or on charity from abroad. Society is free to turn charity into what is considered the right to minimum welfare for every individual-to "put a floor under poverty." But it has to balance the welfare results with the consequences in terms of output. And it has to remember that the volume of output is not merely a matter of technology. It depends on "psychology," on the interplay of incentives and disincentives, and the resultant readiness or lack of it to carry risks and responsibilities, which in ultimate resort deter mine the direction and the measure of the productive effort.

All of which may be boiled down to the preference, again quoting Dr. Jackson, between the two very simple philoso phies: between the conviction that Every Tub Must Stand on Its Own Bottom and the other belief that Every Tub Needs to be Propped Up. 5 From the point of view of a non-communist society, social security stands or falls on the assumption that it contributes 141] SOME· SOCIAL ASPECTS OF MEDICAL SOCIALISM to economic stability. Leaving aside the broad aspects of this question, .this mucn is certified by all experience: .medical. se curity does·not fulfill that goal, whatever else·it· may accom plish. The medical as well as all other branches of social security··can be only a minor factor in the quest for economic stability. As a matter of.fact, their utility for that purpose "is dubious unless economic stability is attained."6 More is "dubious" than that. Actually, compulsory medicine creates ever-new maladjustments, psychological unrests, politi cal conflicts and social disequilibria. It engenders instability rather than contributes to· stabilizing· of the economic system.

There is no sign anywhere, and no serious student has put forth the claim, that the availability of· "free" health care,be it on an Insurance scheme or on a Security plan, has stimulated incentives, mitigated industrial .strife, reduced. absenteeism, forestalled radicalism, strengthened the respect for the law or made labor disclaim higher than "economic" wages. COMPULSORY MEDICINE. SO much has been written about vs. SOCIAL SECURITY social security i~ge~eral that it would fill a major library. But very little has been said about the.specific nature and implica tions of compulsory medicine. Authoritarian. medicine is.the only branch of the security system the major function of which is to provide gratuities in kind. We have discussed the virtually insoluble problems·created by such·a design. As·no·other "se curity" does, this kind necessitates direct, physical controls which threaten to interfere with basic rights and freedoms. It is a difference such as exists between the government's taking over and running a nation's industry and its protection of such industry by tariffs-the difference between· socialism and subsidy.

Of all branches of that great field of humanitarianism called s()cialinsurance, the medical is the least predictable in costs and in consequences. As no other, it tends to foster· the very thing against which it is supposed-to provide insurance. Iron ically, ina world that spends more and more to combat physi ological diseases, more and more psychological incentives for illness.are being fostered.

COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 142 Another unique feature of compulsory sickness care is that it pretends and tends to offer full security of its kind. The idea underlying all other "Security" is to give partial aid only, to furnish a minimum necessary (allegedly) for existence. But in the case of medical benefits in kind, the minimum must be sufficient to restore health, which is the complete service, not just the minimum. This is what constitutes the crucial problem of every compulsory scheme. TOO LITTLE Scant attention is being paid to the fact OR TOO MUCH? that governmentalized medicine performs in one oftwo ways: it provides either too little or too much. It does not fulfill its function of caring for the sick if the care is restricted by bureaucratism and by high costs (contributions and deductibles) to the beneficiary. In that case, "too little" is given from the point of view of the needy who again might have to fall back on charity.

"Too much" is the real danger. Artificial cheapening of the medical services invites an excessive consumer demand which the available means-doctors, nurses, hospitals, etc.-can not satisfy. That, in tum, not only tends to reduce the quality of sickness care to the point where it ceases to be meaningful, but also creates a disequilibrium in the distribution of national resources. The consequences are manifold; they add up to a significant unbalancing factor in the economic system. Free medicine in Britain, as an example, has caused such a rush of adults for dental care that the number of dentists available for the school dental program has fallen from 3,000 to 700.6a Too much of curative medicine results in too little preventive medicine. HISTORICAL When reasoning ends, "historical necessity" NECESSITY? serves as a convincing argument. Ever since Hegel and Marx, the alleged logic of history, construed to fit the constructor's purpose, is the successful tech nique of political and economic propaganda. It works remark ably well. It does so in the hands of governmentalized medicine advocates who use it to provide a pseudo-philosophical back ground.

143] SOME SOCIAL ASPECTS· OF MEDICAL SOCIALISM The idea is that compulsory health security, whether we like it ·or:Qot, is a necessity in industrial society.and as such cannot be escaped. Look at the facts, they say: it spreads·all over the world in the. wake·.of industrial development. That, of. course,would. not prove per se either its. necessity or. its rationality. But the facts do not corroborate the thesis at· all. Actually, Bismarck's Germany of the early 1880's was only at the thresholdof industrializati9n.England,on the other hand, the leading manufacturing country of the epoch, reluctantly followedin the path of governmentalized health care a genera tion later,· more than twenty years after the overwhelmingly agrarian Austro-Hungarian Monarchy. adopted a compulsory scheme. Portugal had a nationalized system long before France; backward and rural Romania preceded by some 30 years ·progressive Belgium teeming with factories; primitive Czarist Russia anteceded an old capitalistic country like Hol land. And when Lenin introduced the most comprehensive and "progressive" health care plan, Soviet Russia probably was the most retrograde of any ~ountry in Europe in terms of per capita motor power. Presently, of all the great industrial nations, only two do not have any sort of governmentalized sickness plan, and they happen to be the world's leaders in industrial mechanization: the United States of America and the Dominion of Canada. In all of this, just where is that famous historical necessity?, If a.modem.country such as Sweden with its very high de gree of industrial. skill is.a late-comer among the governmen talizers of medicine, if Switzerland refuses to go all of the way, and if Finland stands aloof, well, the reason is, we are being told, that toa large extent these nations still are dominated by farming communities. And there is less need for health care in the salubrious atmosphere of rural life, so they say, than in the congestionof metropolitan centers. But the facts are that over whelmingly agrarian countries like Australia and New Zealand are among the leaders in medical governmentalization.. In Germany, on the other hand, the same·advocates of authori tarianism want to extend their system into the farming com munities, and point out rightly the higher rural mortality rate.

Apparently, if one believesin a system,self-contradictory argu ments can be used in its favor without· intellectual embar rassment.

COMPULSORY MEDICAL CARE. AND THE WELFARE STATE [ 144 BALANCE SHEET OF Reduced toa rational denominator, MEDICAL GOV. the "historical argument" boils down ERNMENTALIZATION to something worth serious contempIation. It is this. Disregarding the humanitarian aspects of the question, labor is· the most. val uable "natural resource" we possess. It has to be protected in every way against "depreciation and obsolescence." From a purely economic point of view-if it is permissible in this emo- . tional age to think for the moment in such "inhuman" terms-the implication is that the cost of governmentalized medicine is money well spent on maintaining labor'sproductiv ity, avoiding longer than necessary incapacitation and early invalidity. Eliminating the psychosomatic effects which other wise reduce the output of the worker, whose mind is burdened with the fear of illness, in itself would be a worth-while objective.

Who would quarrel with the obviously sound base of this reasoning? It is as economically sound as is ethically axiomatic the humanitarian argument that the helplessly sick must be cared for. As a matter of fact, if the "statesmen" have been abl~ to make capital of medical care, it is because they could and can appeal to incontesta.ble social reasons and sentiments. But that is not the problem. The problem is whether the sound and desirable objectives on which we all agree could or could not be pursued but by the one and only way of salvation, as the opportunistic politician claims: by recourse to govern mentalized compulsion and to massive subsidies. It definitely is desirable that the public should be protected by compelling every car owner to buy a liability policy. But does it follow by any logic that therefore the casualty insurance business must be nationalized? By the same token, life insur ance companies would have to be nationalized, too, and the amount of the individual's coverage fixed by law. Who would object to providing the indigent with the necessary food? But does it follow that the distribution of food for every one or for all wage earners should be put into the government's hands?

The simple·logic of the matter was expounded seventy years ago by true Liberals-like Lujo Brentano of Germany-who did not oppose Bismarck on dogmatic laissez-faire grounds.7 They actually proposed compulsion, but with the free choice of 145 ] SOME. SOCIAL ASPEPTS OF MEDICAL SOCIALISM the workers to build their own panel organizations or to join any of their liking. This, in essence, is the Swiss system, or it comes nearest to it, although much improvement on it could be made. And the indigent stillcouldbe.~ared for by special charity arrangements-whichneednQt<;J>e. "humilia ting" subsidized by local rather than Ilational governments. Such a system would fulfill the desirable objectives, economic and humanitarian,and would avoid the. political, bureaucratic, financial, and ethical fallacies which corrupt the govemmen talized systems to the serious detriment of national life. Even so, the fundamental fact remains that no country can provide more in sickness care than its economic production permits. Ultimately, the status of health care depends. on the level of wealth, 'not on schemes of one kind or another.

When the, state enters a field of private activity, that field turns into a battleground of organized pressure groups, political and professional, pro and con, often disguised under ideological movements. The one group that is not suited for organization, but tIle one' in whose name all others claim to .speak, rarely receives adequate representation in the literature and even less so in the political arena. The Unknown Patients"lost in the scramble of selfish powers, are the ones whose welfare should be the sole guiding principle of public policy in the medical field. * * * Readers of this book may ask for one free copy of "TheRigh~ Way to Provide Security Against Illness and Old Age," by Willford I. King. Write to: COMMITTEE FOR CONSTITUTIONAL GOVERNMENT, INC. 205 East 42nd Street New York 17, New York 147 Ref,erences by Chap.ters CHAPTER ONE: 1 Jacob Burckhardt, The Age of Constantine the Great, 1852; English transla tion, New York, 1949, p. 62.