Chapter Fourteen. Power Politics in Compulsory Medicine

UI discover in myself something elemental and primitive: a reaction against world data; a refusal to accept any sort of objectivity such as the slavery of man; and the opposition of the freedom of the spirit to the compulsion of the world, to violence, and to compliancy." Nicolas Berdjaev, Slavery and Freedom (1944). C HAP T E R FOURTEEN Power Politics In Compulsory Medicine ASTE, corruption, and bad medical practices are at home to a greater or lesser extent in virtually every compulsory system. The conclusive proof of their omnipresence is the fact that the schemes have to fall back on a multiplicity of unpopular and expensive controls. They tend to increase with the age of the schemes and with their expansion. The systems function the more smoothly the less broad they are in scope and the more limited are the benefits. The nearer the organization is to the comparatively free, competitive and moderately sized panel, as in Switzer land-the less the wear and tear and the less expensive are the controls.

CORRUPTION-A M:ost schemes still are partial or limited SLOW PROCESS experiments. That goes a long way to explain why they do not arouse the public. .But since World War II, the trend is apparent toward making them as comprehensive as is politically feasible. Even so, it takes time before the effects become virulent. The remarkable . thing is not that the comprehensive schemes work badly, but that they work as well as they do. Undeniably, they provide a great deal of vital service to a great many people. If they are not becoming the hotbeds of charlatans, cheaters, maling erers, hypochondriacs and other parasites, if they fulfill their destiny, more or less, it is thanks to the inherent decency of the human element-patients, doctors and panel officials and to the rational responses by which human nature helps to alleviate the evil effects of misconceived political institutions. Ii 124 125} POWER .POLITICS IN COMPULSORY MEDICINE ~t takes time to teach civilized peoples to resort to petty, fraudulent tricks. But there are "smart" ones around who function as catalysts'in the process of demoralization,slow as that process may be. The over-crowded waiting rooms of doctors, infirmaries and panel bureaus, the hospital wards filled beyond capacity, fulfill the, kind of. "educational" func tion that· do··houses'of correction: the' uninhibited braggarts tell their story of getting away with this or that. How often the practitioners themselves oblige by "practical" advice, be it to win customers or to spite the administration, no one knows. Druggists, too; may be inclined to be "helpful" if only by advising the paying client to get on the governmental graY}' train. ControlliJig.and policing help to -<tampen the abuses.. However, new "black markets" crop up when old ones close, and the irritation the controls engender tends to burst into fresh devices to· circumvent them.

BASIC PROBLEMS The dire fact is that physical controls OF MANAGEMENT are, needed in lieu of the scrapped price mechanism. But to be truly effective they would have to be wholly inexpedient. One of the dilemmas that arises, is the choice between quick expedition and "ef fectiveness" in controls. Expedition of each case facilitates administration, saves a great deal of bureaucratic expense, relieves the doctor and pleases the customer. But then, incisive physical controls are out of the question. They are clumsy and costly, the more so the more effective they are supposed to be. They stymie the profession by red-tape and exasperate the patient. Briefly,the choice is between two evils. One is ~ great deal of intervention-in the forlorn hope that it will keep out abuses and corruption-' at the price of high administrative costs and of interferences with the very purpose of the scheme. The alternative is an easy-going and fast-working bureaucracy -slowed down by the ,onrush' of'cccases"-' with .skyrocketing abuses and the wholesale fabricationof medical certificates.

Scheme administrations are confronted with a force as strong as ,human nature itself: the sell-interest of all, concerned, patients and doctors (sometimes also employers) combined. Their silent '~collusion" can not be halted bYe extraneous checks and ,interferences, however costly and bureaucratic. The patients want to draw maximum benefits,. and the doctors COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 126 are impelled to grant all, or most of all, that is wanted. What can be done about that-short of raising deductibles so high (as the French did in the late 1930's) as to eliminate the health "security" of the poor? INTRA-PROFESSIONAL Bevan has solved the problem in POLITICS his own fashion. The cost and. responsibility of control are laid largely on the practitioner. He is "required to keep records of the ill ness of his (public) patients, and of his treatment of them in such form as the Minister may from time to time determine."

He must forward the records to a predominantly lay body, the Local Executive Council, when called upon to do so. They must be accessible for inspection and supervision by a District Medical Officer who is appointed by the Minister. This Officer is entitled also to any clinical information he may re quest. Needless to say, as Sir (Doctor) Ernest Graham-Little has pointed· out, that medical secrecy, to which the doctor is bound by his oath, has been completely suspended. He is being forced to break that oath. Also, unmitigated control by bu reaucratized colleagues, with no parallel anywhere, excepting Russia, hangs over his head like the sword of Damocles. But even the Soviets do not burden their doctors with a similar volume of. time-consuming red tape. So far, the control over doctors by doctors is more of a threat than a reality in Britain. The reality is the paper work which burdens the practitioner. But one interesting thing about this British method is its punitive character. On the Continent, the practitioner is being checked and perhaps over-ruled. Pun itive measures are exceptional. In the British system, he is threatened by penal clauses (Section 35 of the Act) if he has made a mistake, i.e., if he has violated any of the innumerable regulations, even if no "fraud" whatsoever is involved. Little as such punishment is applied so far-the Ministry still is short of personnel-an example is illuminating. An ophthalmologist who acceded to the patient's desire for rimless glasses was not only reprimanded but actually threatened with expulsion from the scheme. And he had no recourse to the Courts. The patients are not under physical controls of any sort, as they are on the Continent, and they may bring their complaints before local organizations and from them to the government agencies.

127 ] POWER· POLI~ICS IN COMPULSORY MEDICINE There is no channel at aU through which the doctor can com plain against the patient.. As a matter of fact, if he refuses to treat one the government might force him to accept the applicant.! On the Continent, the offl,cialhas much less power over the practitioner, although the latter is more often harassed by the former. The French practitioner enjoys more independence than his colleagues elsewhere, which should not be surprising. Even he, however, has to "face the music" but can demand that a "neutral" specialist pass final judgment on the case. The result is that in the provinces' the "neutral" doctor decides seemingly in 100% of the cases in favor of the practitioner who sends him the patients. In Paris, where usually an out standing medical authority is calledin-one who is more inter ested in being called by the panel than in being supplied with patients through the practitioner-90% or more of the cases are decided in favor of the panel. In any case, in France, as in Germany and most Continental countries,disciplinaryaction against panel physicians can be taken oQly through their own professional organizations.

The intervention by official doctors or other experts is highly desirable when called for by the patient and/or the practi tioner. But then, the "control" should be medical,· for the benefit of the patient, rather than policing, for avoidance or detection of fraud. As it is, the constant threat of interference from· "above" means more than a mere irritation to doctors and patients. True, it might help to alleviate glaring abuse. How ,much, is extremely doubtful· in view of the size of the task. Technically and financially, it is not possibleto scrutinize with reasonable efficiency·more than a very moderate fraction of all cases. The cost of doing a more thorough job is abso lutely prohibitive. In. 1947,the primary panel of the. depart ments Seine and Seine et Oise, in Paris, handled a total of 7,000,000dossiers. Of these, 900,000,or 15%, passed through the medical control, but only one-half of them had actually been scrutinized to any extent by official physicians.

What, then, does the medical control over doctors (and patients) actually accomplish? ,This much is certain: the practitioner has to tum into an expert in administrative }>,ro cedure. The laws, regulations, official and semi-official aClvice and announcements, etc., to say nothing of their manifold COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 128 technical interpretations, are complex and voluminous. They constitute a legalistic maze in which he must not let himself be caught. Small wonder that German medical schools have under _considerationthe establishment of chairs for the teach ing of the legal aspects of compulsory sicknessinsurance. LIMITING THE CHOICE The conflict between the scheme OF DOCTORS administrators and their official doctors on the one side and the scheme practitioners and their patients on the other is per manent and irrepressible. It is the conflict between two funda mentally opposed interests. The latter tries to siphon from the scheme as much as possible; the former wants to release as little as possibleso as to protect the scheme against bankruptcy.

The cooperation or conspiracy between the practitioners and patients is irrepressible, too, as long as the patient can choose among doctors, thus forcing them to compete with one an other for the favor of the patient. Free competition among doctors is incompatible with the compulsory system. It might be eliminated in one of two ways. One way consists in stopping the patient from' "shopping" around for doctors. Narrowly limiting the number of eligible doctors, as in-Denmark,-does the trick more or less. Indirectly and to a moderate extent the same effect is brought about by some form of temporary registration. In Germany, the insured has to obtain from his panel in each calendar quarter a sick ness ticket which he delivers to the physician of his choice. The ticket is valid for that particular quarter during which he cannot go to another doctor unless he acquires a new ticket from the panel. As a rule, he "stays put" for the rest of the quarter. In Holland he is restricted to one practitioner for half a year; in Britain he registers with one doctor for a whole year. In either instance switching doctors is possible within the time limits but it is somewhat inhibited, especially so in Holland.

NATIONALIZATION-Of course, this left-handed little THE ULTIMATE device to solve the fundamental OUTCOME illogic of the compulsory system is as futile as are other physical controls, singly and collectively. The illogic consists in throwing open 129] POWER POLITICS IN COMPULSORY MEDICINE the medical services to ·an unbridled demand, on the naive assumption that it would not· go beyond what is .absolutely necessary. Only one effective solution for the problem exists. Depriving the patient of free choice among doctors would stamp.out collusion between the two. This, in effect, is what the claim of leading German "trustee-doctors" amounts to: that they should be. consulted in every case involving ab senteeism. That means one thing and one thing only: the nationaliza tion of the profession, bringing it to the status of salaried officials,emasculating its entrepreneurial spirit, and degrading it to a technical adjunct of the bureaucracy.

This.has been fully accomplished.in Russia, and nearly so in the Satellite countries. There, the doctor has become a gov ernment officialat a fixed salary. The population of a Barrack Economy has to content itself with barrack doctors who by loyalty and economic interest are tied exclusivelyto the gov ernment. Their job then no longer is to diagnose sickness.and to cure it. The job becomes: to diagnose malingering and to keep people from pretending to be sick instead of working. Regimentation of one's most private life turns into. a night marish reality. Nationalization of the profession has been partially imposed under the Bevan scheme: so far as the majority of specialists, other than dentists, is concerned. The general practitioners whose overwhelming majority has refused to submit are being squeezed into economic dependency. The final outcome, if the squeeze continues, cannot be doubtful. The doctor's free dom to choose the location of his practice is already lost. [n Belgium, Austria and elsewhere the same objective is being pursued. by "competitive" methods: official polyclinics and ambulatoria serve to displace the practitioner step by step.

Scheme doctors have been "nationalized" in Portugal as well as (already under the pre-war legislation) in Yugoslavia, Hun gary and Romania. The conflict between administration and profession is under way in every scheme. As a laboratory science, perhaps, medi cine.may operate under a totalitarian regime. As .anart, it can flourish only under freedom. The ultimate .showdown in medical organization must result either in thoroughly reducing COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 130 the operation of the compulsory schemes, or in profoundly curtailing the basic liberty and human rights of all those sub jected to them, patients and doctors alike. BUREAUCRACIES It may strike the reader as ironical FIGHT-FOR FREEDOM that the panel bureaucracies are up against the problem of preserving their own freedom. But the fact is that the rule over the panels is also an object of power politics. This is a miniature edition of the eternal conflict between local self-government and cen tralized administrative power.

The problem does not pose itself in a set-up of free panels, as in Switzerland. Their autonomy is not impaired by federal supervision of a type reminiscent of public utility regulations in this·country. However, the question of power-relations arises at once under any sort of compulsory system. Its manifesta tions vary in accordance with the type of organization outlined in Chapter IV: decentralized panels, as in Germany, Austria, Holland, Belgium, etc. (also under the old French and British schemes) ; semi-centralization, as in France, and total centrali zation, in Russia, the Satellite countries and Britain. From Bismarck to Hitler every German governmental sys tem, including that of Wilhelm II and the Weimar Republic, had made attempts to put the sicknesspanels under the rule of the federal bureaucracy. Every attempt has failed so far. So did the propaganda of the post-Nazi socialists in Trizonia for "unification. "

Bruning clipped the panels' wings by making mandatory significant rules which, before, they were free to elect or to reject. All Hitler accomplished in the organizational direction was to merge (in 1933) all panels for salaried employees into a single, huge unit. German panel officials were and are as adamant and emotional regarding their freedom from regi mentation as are the doctors regarding theirs. The French departmental panels-operate in. a curious twi light of semi-independence-characteristic of the compromis ing inconsistency and lack of clear directive inherent in the political structure of the Fourth Republic. Nominally, they are autonomous agencies within the narrow confines of the 131 ] POWEltPOLITICS IN COMPULSORY MEDICINE law. But the. Ministry of Labor has veto power over every move· they make and.·bombards them with circulars, ordin nances and arretees defining allddirecting their activities in minute detai1.2 In addition, the Ministry of Finance tries to put its "big toe" in the door of the Social Security under fiscal pretext: to supervise the financial operations. The wire-pulling and intriguing between the two ministries might be worthy of a French comedy. Parliament itself is of two minds on the issue. In 1947, a law was passed permitting the incorporation of new sickness funds having at least 100 members. They became automatically branches of the respective panels. This was a step toward decentralization. But on the other hand, strong forces are at work to throw the whole system into the laps of the Ministry of Finance. Complete "nationalization"

would permit economic operation, the argument says. The op ponents ask sarcastically: what about the deficit of the nation alized industries? As it is, the French social security bureaucracy hasdevel oped ·a .political power of its own, as shown by the ·fact that it almost brought about a cabinet crisis in the summer of 1949. The socialist Minister of Labor, Daniel Mayer, author ized arbitrarily an extra month's salary for the employees of the securite in addition to the usual one month's paid vacation. The ensuing political quibble about this "14 months'pay" shook the parliamentary structure of the' country. COLLECTIVIST Even the Soviets. experimented with a ADMINISTRATION semblance of self-government. Under the Nep, in 1923, when markets were restored (temporarily), Lenin based his sickness security sys tem on "cells": the pl~t units and professional organizations. In each of the member "republics" of the U.S.S.R. a central office (glavsotzstrach) of 5 trade unionists and 8 representa tives of diverse commissariats was to do the directing. The crowning link of the hierarchy was the Central. Directory of Social Insurance (tzoustrach) in the Moscow Commissariat of Labor. 3 Stalin abruptly; ended this idyll of false pretenses.

In 1937, in the midst of the great purge, the whole set-up was abolished, and. the central bureaucracy took over hook, .line and sinker..The Commissariat (Ministry). of Social Assist ance took over the handling of cash benefits while the medical COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 132 and hospitalization end fell to the Commissariat of Public Health. The essential feature of Stalin's organizational regime has been copied by Dictator Salazar in Portugal and by the "dem ocratic" Labor regime of Great Britain. The latter has copied even the dividing of the scheme between two ministries. THE RATIONALE Centralization means the ultimate of OF ORGANIZATION large-scale organization-· with all the disadvantages but with few, if any, of the advantages of large-scale production. The larger the man agerial unit, the more bureaucratic it tends to be, the higher the costs of operation per member, and the less the members receive in actual benefits in kind. German experience provides conclusive material. In low administrative costs as well as in high medical benefits disbursed, both per capita, plant panels (betriebskassen) make the most favorable show, with the semi-voluntary "substitute" panels (ersatzkassen) close sec onds. The huge metropolitan units (orts-krankenkassen) rank on the opposite end of the scale. This is as would be expected.

The German panels themselves claim that the optimum size is reached with 50,000 to 60,000 members as against the hun dreds of thousands in the large units. (The Bavarians favor even smaller panels, and so do.some Swiss experts.) Small size may mean less "perfect" risk distribution, but that turns out in practice to be more than compensated for by other factors. Better, more personalized service to, and control of, the patients by the officials-and of the officials by the members-are de cided advantages of the small unit. Al'80, much if not all of the administrative work is performed by voluntary forces. Instead of an expensive building the part-time use of available office space may do; employees usually are available for part time work at little or no extra cost, etc. Also, the checking by members of one another's sicknesses is the most effective and cheapest way to restrain spending. Above all, the smaller the unit the less "imperialistic" are its ambitions. Instead, it tends to drive for economies. Small wonder that the admin istrative cost coefficient of such units often is close to-zero.

They are often subsidized, too, by the plants. In Germany, Switzerland and Finland, supervision or actual management of 133 ] POW~R POLItIC'S IN COMPULSORY MEDICINE " .. > the plant panel by the plant has been 'a. fa<:tor in achieving comparatively far better records (lower costs and higher bene fits) than those of the average pane1.4 In the minuscule Swisshealth cooperatives, with a few hun dred members each, the cooperation goes so far that the members mutually nurse each other. Of course, such idylls are scarcely feasible in industrial centers, and certainly not for the millions forced into compulsory "cooperation." Being forced they lack that kind of spirit or develop one of the oppo site tendency. THE MEANING OF Such "trivial" details as costs and effi "UNIFICATION" ciencyare of small import to the statesmen who drive for centralization and unification of the social security set-ups. They claim that uni fying related services and running them in a centralized fashion is the "logical" thing· to ,do. It is logical indeed from the political angle. It provides the political boss with a power to dispense favors that is a most effective vote-getting instru ment. It also 'pro0des for a uniformity that is dear' to the collectivist hearts. 5 Wherever govemmentalized .Medical Insurance of a limited scope has been .replaced by an all-embracing Medical Security -be it in Russia, England or France-multilateral expansion coincides with the drive toward centralization. The underlying link between the two apparently unrelated tendencies should be obvious. (See Chapter V.) nUtopias are realizable. Life marches toward the Utopias. And perhaps a new century begins, fl century in which the intellectuals and the cultured class will dream of means to escape the Utopias and to return to a non-Utopian society less 'perfect' and freer." Nicolas Berdjaev.