AFP 50 Years Ago
Am Fam Physician. 2000 Aug 15;62(4):727-730.
This feature is part of a year-long series of excerpts and special commentaries celebrating AFP's 50th year of publication. Excerpts from the two 1950 volumes of GP, AFP's predecessor, appear along with highlights of 50 years of family medicine.
This feature, titled “Medicine and the Hoover Report,” is reproduced from the June 1950 issue of GP. It was written by John S. DeTar, M.D, who served as president of the American Academy of General Practice in 1956–1957, and was chosen Michigan's Foremost Family Physician in 1948. The commentary was written by Sam A. Nixon, M.D., who has been a member of the Academy for 45 years and served as Academy president in 1980–1981.
“Prophecy: an inspired utterance of a prophet; a prediction of something to come.”
This article truly fulfills the definition quoted above. The following excerpts from Dr. DeTar's essay give the flavor of his presentation.
“There is a terrific battle in progress in this country today between the leftists who advocate an all-powerful, paternalistic, collectivist welfare State in which the people will be supported and controlled by a benevolent centralized power in Washington, and the rightists who advocate the traditional American method of free enterprise and individual responsibility, in which the state is supported and controlled by the people.
In the first case, the sanctity of the State is supreme. In the second, the sanctity of the individual is paramount. The solution to the problem of our modern social order probably lies somewhere between the two extremes….
In general, the advocates of control of medical service follow this line of argument: Many people are dying needlessly because of lack of care. Few people can afford the care they need. There are not enough doctors and not enough hospitals to care for the sick. Neither local nor state governments, nor private nor voluntary agencies can do the job, therefore the Federal Government must assume this responsibility. It is the same pattern of attack used by the bureaucrats urging federal control of education, agriculture, and public utilities. In general, those who oppose government medical care use the following points: Government sickness care would defeat its own purpose, costs would skyrocket, and the quality of service would go down. The individual in most cases is able to handle his own sickness care, and the rapid growth of voluntary sickness and hospitalization insurance plans attests the capacity of the people to solve their own sickness problems without government intervention. The Federal Government, by the nature of its own inadequacies, is incapable of assuming this responsibility for the people….
The President has given to the people a complete plan for their sickness care, all made to order by the team of Falk, Altmeyer and Cohen, with the blessing of Oscar Ewing (all employees of the Federal Security Agency). They call this plan ‘National Health Insurance.’
…[We] have for our consideration two points of prime importance. The first point is this: The National Health Insurance Bill (S. 1679), Mr. Ewing's plan for sickness care, does openly and definitely establish federal control of all sickness care. The second is this: The Hoover Commission Report provides overwhelming proof that the Federal Government is manifestly unqualified to assume the responsibility of sickness care on behalf of the people….
The scheme is called the ‘National Health Insurance and Public Health Act.’ It covers 163 pages. Over a third of it is devoted to compulsory sickness insurance—60 pages. Of these 60 pages, 24 are given over to a description of decentralization of the administration of the scheme: local committees, local professional committees, state administration, etc. Each state is described as free to set up its own plan for sickness within the national scheme. However, careful reading of these pages provides conclusive evidence that local and state control are not even contemplated—that the claim of decentralization is simply a sham—a blind behind which the socializers are hiding in order to lure their game into better shooting position.
Like all other Federal plans, the whole scheme is to be run by a Federal Board in Washington. This Board is to pass on state plans. The power of this Federal Board is stated in the bill: ‘In the event of disapproval of any plan…submitted by a state…. the Board shall notify the state of such disapproval’….
Thus, the Washington bureau may completely bypass the Governor and the people of the State, and can run this Federal sickness care system by Federal edict. This is hardly what one can call ‘local administration’….
Repeatedly, we find throughout the scheme this phrase: ‘In the discretion of the Administration.’ The administrator and the Board have the power, according to the exact wording of this bill, to set up a federal system of sickness care in any state regardless of the wishes of the people of that state….
Elsewhere in S. 1679, we find provisions for the registering of complaints by citizens—complaints about poor medical service, about doctors, and about hospitals, all of which can be expected under any government system of sickness care. These complaints are to be heard by tribunals to be set up locally. Such tribunals would be part of the Federal system and would operate according to rules laid down by the Federal Bureau and its Administrator. This point is a vital one; it involves extensive control of the people by the Federal Government, with an elastic power of taxation by direct and indirect methods. Approval or disapproval, authority to make regulations, tribunals to hear complaints, are all controlled by a Washington Bureau. The pattern is all too familiar….
Even a casual perusal of the Hoover Commission Report actually provides overwhelming evidence that the Federal Government is manifestly unqualified to assume the responsibility of sickness care on behalf of the people.
The Report discloses excessive costs, gross inefficiency, shocking waste, amazing overlapping and duplication of services, not only in medical and insurance fields, but in practically all fields investigated. The disclosures of this Commission are not the imagining of a group of reactionaries bent on self-benefit. They are the findings of a group of 300 leading citizens from all walks of life, directed by a bipartisan commission of 12 selected by the President and the Congress, divided into 24 task forces working on 24 specific problems with just one purpose—to collect and present the facts….
Apparently no one either in or out of the Federal Government knows what the proposed system of government sickness care will cost. S. 1679 hints that it might be about 3 percent of the payroll. One wonders about the accuracy of this estimate…. One hesitates to think what the final cost of unlimited sickness care would reach….
Some of the conclusions of the Hoover Commission: ‘The enormous and expanding Federal medical activities are devoid of any central plan. The government is moving into uncalculated obligations without an understanding of their ultimate costs…. The entire report on medical services adds up to a strong indictment of Federal administration of sickness care. Gross waste was found, and more waste planned for the future….’
Dr. DeTar concludes: ‘Are you shocked? You should be. Apparently waste and inefficiency are inherent in the operations of our Federal Government. The Hoover Commission has ferreted out the defects, and has pointed the way to their cure, tempered with the warning that some defects are so serious that no solution can be foreseen at present.’
As a 1950 graduate of the University of Texas Medical Branch at Galveston, I've had the opportunity over the past half-century of private rural practice, teaching and administration, and as associate medical director of an insurance company, to observe Dr. DeTar's fears and predictions come true in piecemeal fashion, by fits and starts, with some successes and not a few failures. Consider the political efforts leading up to the passage of Medicare/Medicaid in 1965, followed by a torrent of regulations. Then there was the cascade of alphabet terms: PSRO, RMP, OSHA, CLIA, GPSI, HMO, PPO, ADA, BBA, etc., each of which affected the practice of medicine, especially through the disruption of the patient-physician relationship in various ways.
That this nation rejects a massive overhaul of the health care system became evident when the present administration tried to manipulate a takeover of one seventh of the national economy through a secret, probably illegal, process, which when finally exposed, was remarkably similar to the bill studied by the Hoover Commission in 1950. In my conversations with younger physicians and in my reading,1 there does seem to be a move to return to individual responsibility and accountability.
This move is accepted by patients who recognize their relationship with their physicians as separate from their contracts with their insurance carriers. While a physician may assist the patient with the paperwork, the physician remains responsible to the patient to render satisfactory care, and not the insurance carrier; payment to the physician for services is the direct responsibility of the patient, while the third-party carrier is responsible for its contractual obligations to the patient.
For the past 35 years, since Medicare/Medicaid came into being, money has been the contaminant in this equation. While necessary to commerce, money has muscled its way into the patient-physician relationship in an unseemly manner.2–4 In my early years of rural practice, the precept laid down by a revered professor held true: “Take care of your patients and they will take care of you.” Even at $2 office calls and $40 home deliveries, my wife and I started a family and built a successful practice. Were the clock to turn back suddenly and I to enter practice again, I would care for the patients as a family physician in a responsible, free-enterprise manner, and take Dr. DeTar's still timely warnings to heart.—sam a. nixon, m.d.
REFERENCEshow all references
1. Murray JL. Family medicine: return to counterculture? Fam Med. 2000;32(2):129–30....
2. Kao AC, Green DC, Zaslavsky AM, Koplan JP, Cleary PD. The relationship between method of physician payment and patient trust. JAMA. 1998;280:1708–14.
3. Freeman VG, Rathore SS, Weinfurt KP, Schulman KA, Sulmasy DP. Lying for patients: physician deception of third-party payers. Arch Intern Med. 1999;159:2263–70.
4. Wynia MK, Cummins DS, VanGeest JB, Wilson IB. Physician manipulation of reimbursement rules for patients: between a rock and a hard place. JAMA. 2000;283:1858–65.
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