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one can either pay the money in taxes or in higher health-insurance premiums. But in such a situation, it is
probably more efficient to choose one or the other and the trend unmistak-ably is toward universal health
insurance in this country. Dr. John Knowles notes that many Amer-icans are required by law to arrange
insurance for their cars; why should they not also be required to arrange health insurance for themselves?
Sixth, lest private health insurance seem a finan-cial panacea, one should note that private compa-nies
are often irrational in their payment procedures. For example, for many years one could not collect
for certain treatments such as the setting of fractures unless one were admitted to the hospital, at least
overnight. Thus a person who might easily receive therapy in the EW and be sent home had to be admitted
in order to re-ceive insurance coverage. This unnecessary admis-sion raised the total cost of health care,
and ultimately such increases are passed on to the con-sumer in the form of higher premiums. Some of
these odd payment procedures have been changed, but not all.
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Seventh, the American medical system in its full spectrum from the private specialist's office to the
municipal hospital wards has never been able to structure the kind of competitive situation that
encourages and rewards economies. Nor has American medicine tried. The American physician has
been grossly irresponsible in nearly all matters relating to the cost of medical care. One can trace this
irresponsibility quite directly to the American Medical Association.
For the past forty years, the American Medical Association has worked to the detriment of the
pa-tient in nearly every way imaginable; it is a pecu-liarity of this organization that it has worked to the
detriment of physicians, as well. Dr. James How-ard Means has said: "Its ideology is very like that of the
big labor unions ... it has now set up a con-tinuing political action committee quite like those of the
fighting labor unions. Every attempt that has been made by liberally minded groups to improve medical
care and make it more accessible ... the AMA has attacked with ever increasing trucu-lence.... They
forget perhaps that medicine is for the people, not for the doctors. They need some enlightenment on this
point."
The truculence of the AMA has been expen-sive. In terms of the modern-day cost of medical care,
we may cite the following points. Beginning in 1930, it opposed voluntary health insurance, such as Blue
Cross. In 1932, it opposed prepaid group-practice clinics. In 1933, it began a suc-cessful campaign to
block the construction of new
medical schools and limit enrollment in those already in existence. We now have a shortage of doctors.
More recently, the AMA spent millions probably no one knows exactly how many millions to fight
Medicare, a program that resulted in health benefits to 10 per cent of the population and vastly increased
income to physi-cians. (Indeed, a good gauge of the AMA's short-sightedness can be gained by
imagining the outcry from private doctors should anyone now try to repeal Medicare.) Further, the AMA
has failed to take any strong stand on prescription pharmaceutical prices in this country, which nearly
every objective observer regards as grossly inflated. And more insidiously, the AMA has per-mitted
what may politely be called blind spots in health care. The Journal of the American Medical
Association refused to print a government study of combination-antibiotic drugs which concluded that
many of these expensive medications are ei-ther worthless or dangerous; the AMA has still failed to
condemn cigarette smoking despite over-whelming evidence that this habit, though profit-able to certain
industrial groups, is directly responsible for much disease, suffering, and med-ical expenses in this
country.
One can only conclude that the American Med-ical Association has not considered the interests of
patients for forty years, or perhaps longer. On the basis of its record, it is opposed to both better and
cheaper medical care. Its only commitment is to
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the doctor's bank account and even then, it makes astonishing errors in judgment.
In 1967, in his inaugural address, Milford O. Rouse, the incoming president of the AMA, de-plored the
growing sentiment in this country that medical care was a right, not a privilege. His opin-ion was not well
received by an angry public, and later presidents have been more circumspect in voicing their views.
Nonetheless, it is customary for AMA presidents to travel about, speaking to groups of doctors, applauding
what they call "the phenomenal growth of the health industry."
That growth cannot be questioned. Personal consumption expenditures for medical care rose from $7.5
billion in 1948 to over $27 billion in 1965, and more than $50 billion in 1968. By 1975, it is expected to reach
$100 billion or more. This is the sort of news to make a Wall Street broker squeal with delight. But
medicine is a service, not an industry, and one really ought to look at it dif-ferently.
In fact, the United States spends more of its gross national product (6.2 per cent) on medical care than
any other country in the world; it spends a larger absolute sum than any other country in the world. Yet by
most objective standards of health infant mortality, life expectancy, and so on it is far from the leader.
Other countries are doing better, and most of them have some form of socialized medicine. The United
States is extraordinarily backwards in this respect. However, many clear-headed American
observers have looked at European socialized sys-tems and have come away shaking their heads; and
there is a widespread doubt whether any European system can be adapted to this country. Very likely,
America will have to work out its own system. The combination of group insurance with a group-practice
system (essentially the system at Kaiser and others) seems a feasible, economical, and practical method,
acceptable both to doctors and patients.
Without question, the notion of the doctor as a legitimate fee-for-service entrepreneur, making his fortune
from the misfortunes of his patients, is old-fashioned, distasteful, and doomed. It is only a question of time.
Ultimately, however, it is not useful to lay blame, whether on physicians, health-insurance
ad-ministrators, politicians, or an apathetic public. For they all seem to share a common blindness a to-tal
failure to understand why hospital costs are ris-ing. In 1967, the average cost of a hospital room in America
increased 15 per cent. What is happen-ing?
The per-day room charge is the largest single item in the hospital bill. There are many ways to break
down this charge as many ways as there are accountants but the clearest is the follow-ing.
In 1969, the cost of a semi-private room at the MGH was $70.00. Breaking this down, we find:
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PER-DAY ROOM CHARGE! $70.00
Utilities, housekeeping, maintenance,
plus business offices ("hotel expense") $ 6.96
Food and special diets 5.82
Nursing 18.42
Labs, records, house staff,
X rays, and pharmacy 28.80
Overcharge (to cover welfare debts) 10.00
Total $70.00
Now this breakdown contradicts one of the old-est complaints about hospitals, as quoted in a na-tional
magazine: "My work puts me in contact with hotels and hotel management and I know that a good hotel
can give you a beautiful room for $30.00 a day, with three meals, and make a profit and pay taxes. And yet
any hospital, which doesn't pay any taxes, operates in the red for $65.00 a day. I say it must be poor
administration."
If the analogy were true, the conclusion would be correct. But the hospital is not a hotel and in any
case, its "hotel" costs are quite reasonable at $6.96 a day; this is approximately half the cost of a decent
motel room in Boston. The charge of $5.82 for food, or approximately $1.95 a meal, is equally reasonable,
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