the past, provision must be made for them through public funds or philanthropy. The evidence suggests that many of them are elderly, impaired, or underendowed, or are widows or deserted women or their dependents. It is doubtful if they could be effectively covered by compulsory insurance because they would lack the means to attain and maintain an insured status.

"The large majority of American families have the resources to pay for adequate medical care if they elect to give it a high priority among the several objects of expenditure. The issue is not whether they can afford medical care but whether they should be compelled by law to pool their risks and to give payment for medical care a top priority. The major alternative for people with ability to pay is to leave them free to determine for themselves what medical care they desire and whether they will pool their risks through voluntary arrangements."

THE VOLUNTARY NONPROFIT HOSPITALS

The voluntary nonprofit community hospitals, as stated above, are those which care for most of the self-supporting population when hospital care is needed. They comprise the group most completely independent in every way, most characteristic of the American spirit in that they were in every instance founded by leaders of the community to meet the needs of the community; and they are virtually unanimous, in the same spirit of independence and community control in which they were founded, in their opposition to a Federal plan which would make practically all of their patients Federal patients.

These hospitals fall into two groups-the church hospitals and the local nonsectarian community hospitals. Their service in 1947 is shown by the following figures:

It might be added here that another group of general hospitals comprises those under private ownership, operated for profit, and performing a useful service in many localities. They number 1,067, and in 1947 served 1,332,498 patients, this very considerable number presumably paying their own way, with or without some prepayment assistance.

As the figures relating to the great nonprofit group clearly indicate, these hospitals, founded and operated as independent community services, and having about 300,000 beds, are actually carrying the lion's share of the general hospital lead. Of the total admissions to general hospitals, 14,665,195, these church and nonsectarian community institutions handle, for example, just about two-thirds, as against the one-third handled by all other general hospitals, governmental and proprietary. Of the total of 2,837,139 births in hospitals of all types, their proportion is even higher-over 72 percent. Incidentally, official estimates declare that 82 percent of all live births in the United States in 1947 were in hospitals, as eventually of course it is hoped all births may be; but the present record is a magnificent achievement of the American system of hospital and medical care as it is, and eloquent proof of the fashion in which it is serving the people.

The patients in these hospitals are for the most part pay patients, sent by their physicians or surgeons. Some have private rooms, for which they pay more than actual cost to the hospitals, because they want complete privacy or some other aspects of luxury care. A large proportion, to an increasing extent Blue Cross subscribers, since these prepayment plans now cover the country, occupy beds in rooms with one to two or three other patients, where the charges are lower than for private rooms; and others are in the large wards, where many of them are cared for without any charge or at rates considerably below cost, But all who enter the doors of these hospitals are cared for, and their doors are never closed.

For some people, notably those who occupy private rooms, the bill involved in the complex of services offered by the hospitals (bed and board, general nursing

service, laboratory, X-ray, operating or delivery room) may be taken in stride.
For most, however, either careful saving in advance of the contingency or some
form of prepayment is highly advisable. People save for vacations, for Christ-
mas; they do not always save for serious illness or surgery, because these
matters are not predictable and, of course, are not anticipated with pleasure if
at all. None the less, the citizen who knows that accidents may happen and that
death and taxes-especially taxes-are certain is to an increasing extent taking
care of the needs of his family for hospital care by some form of insurance.

Blue Cross plans and the commercial insurance companies offer various means
of prepayment which are everywhere available, the latter also covering medical
and surgical care, for which on a voluntary nonprofit basis the Blue Shield plans
sponsored by the doctors are increasingly available. Taking into account all of the
methods by which the self-supporting and self-respecting American may, exercis-
ing his own choice and consulting his own means, arrange for the insurance of his
hospital, medical, and surgical care in case of need, over 61,000,000 persons are
thus to some extent protected.

An estimate of the total situation might be attempted along these lines: Cov-
ered in some sort of prepayment plan, 61,000,000; indigent or medically indigent
who actually received hospital care (1947 admissions to government hospitals
plus care in voluntary hospitals), about 5,000,000; able to pay without insurance
protection, perhaps 10,000,000; total, 76,000,000. Subtracting this from the total
population of 147,000,000, that would seem to leave about 71,000,000, including
heads of families and their dependents as well as the unmarried adults, or in
the neighborhood of 20,000,000 families. It should not be forgotten, either, that
included in the total population are the 24,000,000 persons who according to the
recent Hoover report receive more or less medical and hospital care from the
Federal Government. It is a question, therefore, how many members of the
20,000,000 families estimated above have needed medical or hospital care, or, need-
ing it, fail to secure it, out of their own resources or from the facilities at their
disposal as citizens. Roughly 1 in 9 of the population actually did receive hos-
pital care in 1947. In any event, only a relatively small fraction of the group
would need the protection they had deliberately refused to provide for them-
selves; and in case of need the typical case is certainly that they are cared for
at their own expense, as a ward of government, or as part of the free service
accorded by the present system.

As to those of the working population whose incomes are so limited that
it is said, with sympathy, that they cannot afford either to pay as they go or to
pay Blue Cross and similar premium charges, they are to be compelled to pay
Federal charges, which may count to 5 or 6 percent, or more, of their pay, out
of their own pockets, in addition to all other taxes, whether they can afford it
or not. Of this seriously illogical and self-contradictory proposal, more later.

The Blue Cross plans

Speaking of prepayment arrangements, look at Blue Cross, because it is by all odds the most successful and popular of all hospital prepayment methodsguaranteeing the needed service instead of providing a limited cash paymentand because it is hospital-sponsored and nonprofit. The totale coverage of Blue Cross (United States and Canada) is now 31,841,136, of which total 29,468,675 are in this country. The growth of Blue Cross from 1937 to 1948, from 1,164,126 to the total indicated, is certainly responsible for the fact that during the same period general hospital admissions rose from 8,349,773 to 14,665,195. (See charts.) In 1947 Blue Cross plans paid the hospitals for services rendered to subscribers $211,392,000, covering 21,700,000 days of care.

When it is considered that this has been accomplished in about 12 short years, and that every State except Nevada is now represented in the roll of some 90 approved plans, it must be said at least that it is a remarkable and commendable achievement. Even "the enemies of Caesar must say this," and the Federal Security Administration's representatives have from time to time paid tribute to the accomplishment, which, however, they regret they must brand as inadequate, and which must, they feel, be wiped out by the compulsory blanket substitution of a Nation-wide Federal system.

They suggest some such employment for Blue Cross plans, thus rendered futile, as their use in collections or bookkeeping; but such suggestions need not be taken seriously. The enactment of Federal legislation setting up a tax system for the support of national health insurance would by necessary consequence destroy Blue Cross, for the obvious reason that nobody would need to be twice protected against the cost of illness, nor would anybody voluntarily pay twice for such protection. Blue Cross would be dead, slain by the deliberate action of the Federal Government. Surely Congress will desire to think of this long and seriously before signing the death warrant.

There is another factor, characteristically American also, which will have to be taken into account while universal health-tax legislation is being considered. It is the fact that organized labor (which in general officially favors the Federal plan because half the cost would be taken from the employer) is rapidly leaning not only to the idea that arrangements for health and retirement purposes are appropriate items in collective bargaining, but that Blue Cross gives the best hospital deal; as it does.

The United Mine Workers, for example, have been conspicuously successful in this respect, with a welfare tax per ton of coal mined which has produced a very handsome fund. Just as the pensions made possible by this fund ($100 a month) are very considerably in excess of the pathetic retirement payments of Social Security, its ability to provide medical care for eligible workers, through Blue Cross or otherwise, might well be much greater than that of even a Federal tax-based fund. Certainly the case for welfare arrangements in collective bargaining would be seriously weakened should a Federal plan be adopted, for here again the employer, who would have to pay both ways, would be well within reason in objecting to paying twice. Thus the Federal plan would inevitably tend to destroy welfare provisions arrived at through collective bargaining by organized labor, precisely as it would destroy Blue Cross and other voluntary plans.

An eloquent tribute was paid recently to the part which Blue Cross plans have played in enabling organized labor to bargain for protection against the costs of hospitalization, by Harry Becker, director of the Social Security Department of the International UAW-CIO, Detroit. Mr. Becker said:

"What labor wants for the one out of four families who are going to have a hospital bill this next year is a slip on leaving the hospital which reads: 'Your hospital bill has been paid in full.' There was a time when this goal was 'skypilot' thinking; but today this idea does not belong in the stratosphere-we have demonstrated that through collective bargaining we have a practical approach to the problem of financing on a prepaid basis full prepayment of the costs of hospital care for every working man and his family. This demonstration has been made possible because of the kind of joint labor-Blue Cross cooperation existing in such instances as the Michigan Hospital Service and the International UAW-CIO." In the light of a very recent development, the completion of plans under which employers operating in more than one State will be able to enroll their employees in Blue Cross on a national uniform basis, if desired, as in commercial insurance plans, Mr. Becker's further remarks are especially interesting:

"As unions move into social security as a major collective bargaining issue we are looking to Blue Cross to take the next important step. This step is a national

Blue Cross plan which will provide for universal coverage with the same standard of 'full-payment' benefits for all of the employees of a single employer even though the employees may be living in a number of different States. This means Nationwide cooperation among all Blue Cross plans to assure national coverage of workers, wherever they may live, when a national labor-management program is set up under collective-bargaining contracts whether negotiated in Detroit, Pittsburgh or Los Angeles. Labor is expecting that Blue Cross will not delay taking this next step-now!"

Blue Cross has taken this step, as stated, largely in direct response to the reasonable demands of labor for national Blue Cross coverage, with complete service contracts guaranteed (as they are) by the voluntary nonprofit hospitals who are the actual partners of Blue Cross. The destructive effects of a compulsory Federal plan would thus involve directly not only Blue Cross, but the results gained in its utilization in industry through collective bargaining for hospital-care arrangements.

Would this be wise, or just? Is it necessary? Is it desirable?

THE FAILURE OF GOVERNMENT MEDICINE

Henry, the young Virginia orator of the Revolution, remarked on an historical occasion: "I have but one lamp by which my feet are guided, and that is the lamp of experience. I know of but one way of judging the future, and that is by the past."

This is a sound view. Holding up the lamp of experience, therefore, in connection with the question of whether under Federal control a compulsory system of individual health care should be imposed, and attempting as well as may be to judge the future by the past should such a system be established, several matters suggest themselves for consideration. One concerns the operation of hospital and medical care by Government, particularly by the Federal Government, in this country, and another concerns the operations of social-insurance systems, including health care, in other countries, such as Germany, Great Britain, and New Zealand; all of which have furnished a record of experience in this line. Remember the Navajos?

In this country there is an exceptionally impressive example of Government medicine as it actually works, in the case of the Navajo Indians, as reported about a year ago to the Department of the Interior by Dr. Haven Emerson, one of the country's most widely known and experienced physicians, on behalf of the Association of American Indian Affairs. This report, which was widely publicized, covered in detail the disgraceful conditions prevailing as to health among the 81,000 Navajos, wards of the Federal Government ever since their final conquest in the seventies.

Dr. Emerson's report stated that with grazing for their flocks arbitrarily reduced, also by Federal authority, the Navajos are existing on 1,200 calories a day, less than the Germans received immediately after the war; that many of them are so weak because of this inadequate diet that they cannot stand sustained exertion: that there is one social-service worker for the entire tribe; that more than 10,000 are eligible for old-age assistance, aid to dependent children and aid to the blind, but are not receiving these services; and that mortality rates are so high, resulting from the total or partial lack of the medical services they need and are therefore entitled to, that Government economy in this respect appears to be purchased routinely with Navajo lives. A tuberculosis infection rate 14 times the average of the country as a whole is one pointed index of the situation.

The number of hospital beds in the generally excellent institutions operated by the Bureau of Indian Affairs appears to be adequate: but roads are almost entirely lacking, and the Navajos do not possess cars. The situation, in brief, has been and remains perfect for the kind of active public and individual health care, outside of or in the hospital (including out-patient care), of which the Federal authorities think they should be given permanent and exclusive charge for everybody. But medical care, in particular, has hardly been given at all to the Navajos, the very special wards of the Government.

Apprised of the situation somewhat belatedly, Congress has taken steps to remove this disgrace from the Government's continuing record of ineptitude in health matters; but the facts constitute an unanswerable challenge to the ability of a distant central government to give even minimum health care to the Nation as a whole, since it has failed so miserably in this limited area.

Aside from this curious, significant and depressing instance, and with the qualification that, of course, there are good hospitals operated by government, including the Federal government, and without raking up old ashes-some not so old to start fresh fires, it must be said that as a rule the voluntary nonprofit community hospital, of which this country fortunately has so many fine examples, averages very much better indeed than the Government hospital. There have been and doubtless still are some hospitals in the voluntary group which are not as good as they should be; but there have been among them no such scandals of corruption, mismanagement and bad service as have risen to the horrified view of the public from the institutions operated by Government at all levels.

It is not always remembered, as an outstanding example of an important aspect of medical care chiefly under Government control, that mental cases are almost entirely hospitalized in tax-supported institutions, State or Federal, and that the record of these institutions, for whatever reasons, has furnished the unpleasantly authenticated background for such recent studies as "The Snake Pit." As a leading psychiatric authority commented 2 years ago (Dr. C. Charles Burlingame, Hartford, Conn.). "For over a hundred years 95 percent of the practice of psychiatry has been State medicine," adding that "before going further along the road toward political handling of medical care, the people should demand that the ability of State medicine be demonstrated first in its present responsibilities." Said Dr. Burlingame further:

"Why ask for new worlds to conquer when the obligations already belonging to socialized medicine have been so scandalously neglected? Why ask for more when a concentration of all efforts and resources in this one field which is already the Government's, offers the greatest single opportunity to bring health to the greatest number?”

There has been no adequate answer to this logical question, from any quarter. The painstaking investigation of the veterans' hospitals, for example, by the American Legion and other organizations of former servicemen, occurred not too long ago for the memory to be quite fresh of the conditions which they revealed. The mess, once revealed, was finally cleaned up by the prompt and aggressive action of the new head of the Veterans' Administration and his able assistants; but the record of what miserable conditions had accumulated over the years, under complete and undisputed Federal control, should not be forgotten. The tendency of hospitals operated or in any sense controlled by Government toward such conditions will always remain, for reasons which everybody understands. The curious thing is that, this being the case, there are people who are not only willing, but anxious and determined, to turn over to governmental control, in the fullest sense of the word, all individual health care. Congress will have to consider with the utmost seriousness this tendency, which was explicitly referred to some time ago by a great hospital authority, the late Dr. S. S. Goldwater, a personal friend of the late President Franklin D. Roosevelt. Dr. Goldwater was commissioner of hospitals in New York City long enough to find out something about the effect of political control on hospital care. He spent the last years of his life as president of the vast Associated Hospital Service, the metropolitan New York Blue Cross plan, and incidentally in fighting bitterly the then new threat of a Federal compulsory plan. In an address on this subiect delivered in Philadelphia in 1942, the year of his death, he said:

"Local organization and control will produce the best results in hospitalization, and any Federal approach to interference with the fiscal affairs of hospitals, leading eventually to control by a central Government bureau, would be a tragic affair for the people of this country. There is justification for the interest of a humane government in the question of whether hospital service has been made available on suitable terms to the great mass of the people, but this inquiry should also take into account the fact that the voluntary, locally directed hospital service plans have made Government intervention unnecessary.

"Assumptions that we must do as other countries have done, regardless of our achievements, are certainly not justified, especially in a country where freedom is valued and where the principle of local self-government is supposed to be sacred. Even the different sections of our country differ in various ways, so that an actually even performance, uniform everywhere, could hardly be secured if it were desired. I don't want it; we could have it only under strict Government control, and it would be on a level far below what can be achieved under the system we have been developing for so long and so successfully.

"Moreover, failure in a locality, if it must occur, is not the tragic thing that a country-wide failure would be. Hospitals must be left free to take such action as