Chapter Five. The Dynamics of Compulsory Medicine

""'What worries the conservative is not so much the liberal, as his grandson." Peter Viereck, Conservatism Revisited (Scribners, 1949). c H A. P T E R F I v E The Dynamics of CompulsoryMedicine T 1881 Imperial message of Wilhelm I, announcing the compulsory scheme, emphasized that it was the continuation and expansion of traditional poor relief. It was, indeed, just as Lloyd George's project of 1911 was a direct extension of the Poor Law of 1909. In both .cases "insurance" was' used as the form in which to extend relief. But much more was at stake. Poor relief on a governmental level was common to all of Western Christianity since the dawn of the Medieval Age. Essentially, it aimed at two things: to provide "full employ ment," by subsidizing and regimenting business, and to care for the unemployed, including the old, the invalid and the sick, if only in the poor house.1 POLITICAL Since the French Revolution, the care for EXPLOITATION the poor-hospitalization, in particularOF POOR RELIEF became a matter' of municipal concern.

The intention was to free it from political and bureaucratic shackles and to leave it to the self-governing local bodies. Typically, in 1848, the hospital system of Paris, probably the most modern and comprehensive one of the time, was organized into an autonomous public -corporation. What Bismarck did, among other things, amounted not only to revolutionizing the poor relief-by throwing its major financial burden on the shoulders of workers who needed ·no such relief -and on the employers-but also to reversing the process of denationalization. Relief was brought back into the fold of the central power and raised to the high plateau of 43 COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 44 national politics. Bismarck's great "discovery" consisted in a device for making political capital out of poverty and human suffering. .Compulsory medical insurance puts a mechanism of its own into motion. So long as the poor are taken care of on a charity basis, some sort of a means-test provides an automatic check.

The insurance form eliminates that check and all the inhibi tions that go with it. To be sure, it is no insurance at all, since it is not voluntary and is paid by the beneficiary in part only. Nor can it provide any other check implied in genuine insurance, such as the insurer's freedom of choice among the risks and their classification with proper compensation for each specific type of hazard. But even an ~;mpersonal system of subsidies masquerading as insurance offers at least an impediment, for only those can take advantage of it who have an employer to carry part of the premium. Once the principle is accepted that the general taxpayer has to participate in the cost, the basic barrier to expanding the system-from. a limited medical insurance to an all-embracing medical securityis scrapped. HORIZONTAL Institutions on the political level are subject EXPANSION to the dynamics of the political arena. The first of the inherent laws that rule the life of governmentalized medicine is-that it must expand. It does so, in the first place, by force of the natural increase in mem bership. But the artificial growth is what matters. It proceeds horizontally, so to speak, by being stretched to embrace more and more people: family "members, new occupational cate gories, higher income brackets. It may be a slow process, as in Germany, where the panel bureaucracy itself resists it, but the ultimate tendency is to absorb the entire population. That stage has been reached in Soviet Russia, so far as the urban population is concerned, in revolutionary tempo since the Czar's modest, and Kerensky's vaguely broadened scheme, while 15 years passed between Laval's panel system to La roque's generalized (not as yet completed) plan, and 37 years between Lloyd George's and Bevan's. Sweden's voluntar~ panels are supposed to be nationalized by 1951, and a majority of the population included at once. When Franco decreed medical compulsion in 1942, even the self-employed, up to an 45 ] THE DYNAl\IICS OF COMPULSORY MEDICINE income limit, were included. The final in paradox is attained under Bevan-the millionaire and the wealthy foreign tourists (including scores of lepers from the French African colonies) who do ndt even pay taxes are subject to the same benevolence as is the domestic pauper.

This horizontal spreading is due in part to a financial motive: to find new contributors or to justify new·tax levies to balance the schemes. nut almost invariably, financialdisap 'pointment results. Family members and higher income brack ets entering the schemes bring new members with more "refined" medical demands. .As a rule, they cost more in proportion to what they contribute. The horizontal growth may be retarded-it virtually never is reversed. It proceeds with a sort of fatalistic necessity-by the inescapable logic of its own political momentum, from wage-earner to the salaried and self-em{!loyed, from family heads to the family members, from there to the in-laws (in Czechoslovakia, 1920) and to the housemaids (in Hungary). Austria was the first country to force government employees into its scheme. ~f people on income up to $1,000 can get some thing "cheap," which is what govert:tmentalization implies, those earning between $1,000 and $1,100 naturally ask for it, too, or so does some party seeking their support. The $1,100 to $1,200 bracket comes next, and so on, just as in govern mental housing.

VERTICAL The schemes grow vertically, too. The tendency GROWTH is, in the long run, to offer more and more. cash, commodities and services for lengthened periods at less and less (visible) cost to the recipients. If one kind of medical aid can be provided at. somebody else's expense, why not extend the benefits by including some more kinds? Or stretch it to cover every minor·trouble as well, and everything the pharmacies sell? Why not treat the patient for six months instead of two, or for a whole year as in Austria, for three years as in France, or indefinitely as in Germany, Belgium, Britain and Greece? Why not add hospitalization as the Ger mans did gradually, and the British suddenly? And why not raise simultaneously the cash benefits the patients receive, as Austria did after the first World War and Britain after the second? If the beneficiaries are entitled to medical ·care at the COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 46 price of compulsory contributions amounting to two-thirds of the actual cost, as until recently in the German, Austrian and Luxemburg set-ups, why not reduce their share in the burden to one-half as in most obligatory panel systems, in Germany since.middle 1949, or to six-elevenths as in Norway? Or to two-fifths, in France and Greece, to one-third, in Brazil, and pending in Holland, one-fifth, in Peru, and to about one-ninth, in Britain? Why not to zero, as in Italy and Poland, where the employer alone pays? That today is the goal of the Social ist partie~ in France, Sweden, Germany, Belgium and the Netherlands. Obviously the platform has vote-getting merits.

In the meantime, government subsidies are being requested, if not already forthcoming, on top of employer and employee contributions. A chief motive or excuse for the vertical expansion is the failure of the plans to provide what they promise. In Holland, as an example, a modest amount of dental care is offered within the framework of the obligatory scheme. A little dentistry (free of charge) is sometimes worth less than none at all, patients complain. The appetite is whetted for more, and humanitarians soon take hold of the issue. GROWTH OF The lateral growth-by way of broaden BUREAUCRACIES ing the bureaucratic apparatus and add ing to it-is irrepressible, too. As the beneficiaries increase into multi-million figures and the benefits are being diversified, the number of offices and office employees who deal with them must increase accord ingly. The sheer volume of paper work necessitates this expansion: registering, filing, bookkeeping, cashing and dis...

bursing, answering oral and written queries, plus checks and controls, internal and external, bureaucratic and medical, etc. Where the patient has to visit the panel first and last, which is the case in most systems, more and more branch offices are opened so as to be at his or her elbow and to avoid too much queueing. The relation is mutuaL The larger the bureaucracy and the more extended its apparatus, the more it tends to strive for additional functions, or at least controls. The ultimate ideal of most administrations, whether French or British, Austrian 47 ] THE DYNAMICS OF COMPULSORY MEDICINE or Belgian,··is to erect·medical·centersfqr· the convenience of the consumer, which means ·lateral expansion as well as vertical. What is more, political and administrative forces drive toward the "consolidation" of small panels into large units, toward centralizatiQnandunifl¢ation. All of which adds up to enlarging the bureaucratic apparatus on the one hand, and to reducing the ·self-restraints of the membership on the other.

TEMPO OF The surprising fact is that the compulsory sys EXPANSION tems.do not grow by leaps and bounds except when revolutionized, as happened in Russia. Even the recent "eruption" in Britain and France was more apparent than real. It was preceded by several steps of ex pansion.. Extending the benefits to new groups calls each time for legislative action, which slows down the process. But it has become semi-automatic in part, such as by the customary rule of panels that "once a member, always a member"-a rule that permits people who have risen on the social ladder to enjoy the subsidies originally intended for the less fortunate ones. The rule is open to outright abuse-the shop-owner's son registers as a low-pay apprentice and acquires the priv ileges of life-long membership. The extension of membership may be put on a voluntary basis. In Holland, since 1945, the self-employedwith less than 3,750 florins annual income-· now equal to about $1,000, the same limit as for the employed-were permitted to join, which they did in flocks, raising the membership by about 1,000,000.

The same technique has been applied in Germany and in Nor way: opening the doors to "voluntary" members, who cannot afford to refuse the subsidy. The voluntary insured constitute about 15% of the total in Germany. The regular process is, however, to extend the. compulsion step by step. In Germany, it went in slow motion from wage earners· (June, 1883) to salaried employees,apprentices, farm hands and to the handicraft employees, through the legisla tions of 1885, 1886, 1892, 1913, etc. By 1926, under the Weimar ·Republic, the coverage ·was generally extended to the family members. From 21.6% of the population in 1910 the number of insured mounted to about 33% in 1939, and to 65% by 1948, the Social Democrats fighting now to broaden COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 48 the scope all-around. It went faster in France, starting with miners, sailors and railroad men, then including all wage earners since 1930. Since 1945, coverage was stretched to include all salaried people, even the top bureaucracy (but premiums are levied only up to about $1,200 of annual in come), then to cover students, the military personnel, farm hands, self-employed truck drivers and redcaps, and so on.

The widening of coverage to more and more people often has little to do with the actual need of the insured. More often, it has political implications. Each move on the road of "medical imperialism" is greeted as the victory of an ideal, and is being sold to labor, in particular, as a step in the direc tion of "economic democracy." At any rate, the horizontal diffusion since World War I is nearing its limit, covering (on paper) virtually everybody in Argentina, Australia, Belgium, Brazil, Chile, Eire, Great Brit ain, Iceland, New Zealand and Spain. Projects on such a comprehensive scale are in the blueprint stage or are hanging legislative fire in France, in the Canadian Province of Alberta, in Sweden and in the United States (Wagner-Murray-Dingell Bill). Elsewhere, the original idea of providing for industrial wage-earners in the low income categories, and only those in regular employment, has been expanded by inclusion of other occupational groups and ipcome brackets. The vertical infla tion has not reached its limit as yet. In most countries, all medical services and hospitalization are available to all of the "insured" free of charge, with deductibles applied, as a rule, for major dental and physiotherapeutic procurements only.

And where sickness aid ends, disablement benefits step in. But preventive medicine and after-care for the sick still are in the blueprint stage. Italy is the only country to my knowl edge that explicitly recognizes the res~onsibility of the health insurance organization for continuing care for the same sick ness after the patient officially has recovered. Such extension in due course may safely be predicted for other countries. MEDICO-POLITICAL A Welfare State that takes over the IMPERIALISM provision of homes has a job on its hands. But at least it need not build houses for the same people over and over again, or worry too much about rapidly changing fashions in architecture. In the 49) THE DYNAJ4IOS Oll' COMPULSORY MEDICINE field of.health care, almost constant changes are indicated by the fantastic progress along every line. Even·the mode-or fash ion of thinking·as to.the right kind of medical action is in flux.

And, contrary to housing, sickness care is essentially·still in an experimental stage. "Medicine is a collection of uncertain prescriptions, the results of which, taken collectively, are more fatal than useful to mankind. Water, air and cleanliness are the chief articles in my pharmacopaeia." This remark of an embittered Napoleon on Saint Helena to his doctor, Antommarchi, was out of step even with his own time. But certainly, to our grand fathers, it contained more than a grain of common sense. To them, a "sick" person was essentially one who could not stand on his feet. The opposite tendency-over-medication-obtains today. Napoleon's dictum may wen be compared with the stirring caricature by Dr. Herbert A. Ratner, of Loyola University's Stritch School of Medicine, that calls "nature violated when modem man as the result of medical propaganda goes through life-fearing death, expends his health as a hypochondriac, and ends up as a vitamin-taking, antacid-consuming, barbiturate sedated, aspirin-alleviated, weed-habituated, benzedrine~stim-, ulated, psychosomatically-diseased, surgically despoiled ani mal. Nature must be shocked that its highest product turns out to be a fatigued, peptic-ulcerated, tense, headachy, nico tinized, over-stimulated,neurotic, tonsilless creature." Jules Romairt's comedy, "Knock,·Orthe·Triumph of Medicine," in which a charlatan talks the whole town into various ·diseases, ep~tomizes the point that the shining medal of medical progress has a reverse side, too.

What has provided, and provides, a pretext for using the sicknessschemes as playgrounds of very expansive (and equally expensive) patronage is the unrelentingadvance of medical research in the last fifty years. Indeed, the prophylactic, diag nostic and curative practices all are in a continuous, self revolutioniZing evolution. Once the principle is accepted that the compulsory scheme should provide proper care-. what else but the .best and latest, and therefore often the most costly, should be provided? So long as a genuine voluntary insur ance is in operation, the cost of which is· borne by members, COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 50 these members have an incentive to keep their demands with in bounds. But in the compulsory schemes the individual knows of little or no responsibility for the functioning of the whole. On top of that, politicians and/or bureaucrats have every interest in advertising the schemes by procuring the most spectacular and the most modern services. The doctors, too, have such an interest, especially the young ones who want to make a reputation and to amortize as fast as possible their investment in education, in technical equipment, automo bile, etc.

The medical expert tends to be-nay, has to be-"one si<Jed." He must devote his time, his energy and even his emotions. He is inclined to look at the world from the point of view of his intellectual and professional goal. The doctor's ideal is to detect every sickness at the onset, and to "cure" it in the most thorough-going fashion. Sickness is his enemy; to fight it he would mobilize all resources and utilize the best devices. His pecuniary interest drives him in the same direc tion. This natural and .logical expansiveness of the profession tends to grow into imperialistic delusions when the technical tools fall into hands that wield Power. The medical dream becomes the object of exploitation by the ambitious poli tician. The outcome is something which the taxpayers should be concerned about-and the patients. SICKNESS-Once the politician lays his "expert" hand on A PATRONAGE society's medical function, the latter must be GOLD MINE inflated so as to suit the purpose of the former. Senator Antonelli, a first proponent of social security in France, expressed it graphically while proudly summarizing the "great accomplishment" of 1945: "But one must not forget that almost everything is yet to be done in this (medical security) field so as to adjust the medical service to the new institutions. That will be arrived at by multiplying the hospitals' services, the dispensaries, the general clinics of general and specialized medicine, and by preparing and form ing technically and morally medical and auxiliary personnel of the new social medicine."2 Mr. Bevan (or Mr. Stalin, for that .matter) might as well have written these words which sound like one of his own enthusiastic pronouncements. They reflect the medico-political programs in vogue with the Wel51 ] THE DYNAMICS· OF' COMPULSORY MEDICINE farist parties of every color. The ideological source in common is Lenin, of course. ' Expand compulsoryservicesmust, according to the medico politicians who use statistics glibly, ingeniouslyand insidiously.

The Surgeon General ofthe United States Public Health Serv ice (Federal Security Agency) may be quoted as a recent and characteristic example. According to him, of the estimated world population of 2,265,000,000, more than 1,000,000,000 human beings "annually suffer from diseases." Where the Surgeon General obtained these figures or those about the 65% of Egyptians who suffer "from schistosomiasis, the 60% to 70%, who are afHictedwith trachoma, and the 300,000,000 people o£ Asia, Mrica and Europe who are malaria diseased, while one-third of their entire population is syphilitic remains his secret. But such flimsy statistics, drawn from nowhere, serve as a base from which ·to claim financial appro priations and to propose vast technico-hureaucratic organiza-, tions. They indicate the passion which drives patronage hungry medico-politicians and political doctors, shining but as yet little known stars in the firmament of the Welfare State.

To the vested interests, compulsory medical care is the vehicle of this medical imperialism. Whatever· its results may mean to humanity, it means expansion of the schemes ineveryj dimension. So long as they stay within the comparatively narrow confines of the Bismarckian type panels, their wings are clipped; their self-inflating propensity is limited.. But the~ tend to breakout of those confines under the double pressure of medico-political ambitions and the public's dissatisfaction with the "incomplete" schemes. Make them complete-is the catchword. It is hard to resist. Depressions, as in the 1930's, may call a halt to, and even reverse the schemes' (horizontal) expansion, only to burst out with rejuvenated vigor in the subsequent boom. A semi-official but not uncritical French newspaperman, s!1rveying the operation of his country's obligatory set-up and !istenm~ to the plans of. the scheme-politicians, summed up his ImpressIons by suggestIng that the panels should write as a motto on their front doors the words of the fake doctor Knock (in Jules Romain's comedy): "Every healthy person is a sick man who ignores his sickness."3 c H A p T E R s I x Skyrocketing Costs OMPULSORY MEDICINE is in the throes of open and concealed crises. This is true for vir tually every single European scheme and is due to unmanage able costs, which in tum· hinge on the three dimensional· ex pansion trend.