Commentary A National Health Service and Social Security M. 1. ROEMER, MD, With the new federal administration, there is widespread belief that at long last some type of National Health Insurance legislation will be enacted in the near future. The scope of that legislation, in population coverage and health benefits, is bound to depend on the strength and unity of public demand. It is unfortunate, therefore, that at this critical hour voices should be raised rejecting National Health Insurance and calling for general revenue financing of a National Health Service. This is regrettable in the light of both world-wide and American experience on the issue. Improved organization of health service delivery for everyone, through teams of salaried personnel in a regionalized network of public facilities, is clearly desirable. Worldwide trends are moving in that direction, and this pattern is a reasonable goal for the United States as well. To expect such a goal to be attained in current-day America, however, through ""progressive taxes on personal wealth, taxes on corporate profits and general revenues" -in the words of the newly launched Committee for a National Health Service* is to flirt with a dangerous illusion. To understand how a universal and effective system of comprehensive health service can be achieved in a free-market economy, such as characterizes the United States, requires analysis of the issue into its major components. One component is the method of financing health services, and the other is the method of delivery of those services. Each of these components shows a clear evolutionary development in the capitalist world, and each has distinct political implications.
World-wide Experience If we examine the relationships between the statutory patterns for (a) financing and (b) delivery of health care, that *The Committee for a National Health Service was established in 1976 and can be reached at GPO Box 2125, New York, NY 10001. A1ddress reprint requests to Dr. M. I. Roemer, Professor of Health Services Administration, School of Public Health, University of California, Los Angeles, CA 90024. Dr. Axelrod is Professor of
462
AND
S. J. AXELROD, MD
have developed around the world, we find at least four principal combinations. These may be schematized as follows:
Delivery
Financing Individual (1) (3)
Insurance Revenues
Organized (2) (4)
Only combination (4) corresponds to the National Health Service, as perceived by its advocates. The realities are further complicated by the fact that in many nations-such as Sweden, Great Britain, or Chilethere are combinations of both forms of financing within one health care system. Moreover, there are often different patterns of delivery for hospital and ambulatory services in the same system. Thus in Great Britain's National Health Service, hospital care is delivered through organized arrangements, while ambulatory care is still predominantly on an individualistic basis. In Germany, most in-hospital medical care, though not all, is provided by organized staffs of salaried doctors, with ambulatory care by private doctors paid by fees, and this mixed pattern prevails in many European countries. If we focus, for the sake of clarity, on general physician services for ambulatory care, we find that the above combinations may be illustrated in practice as follows: Pattern (1) (2) (3) (4)
Country France Israel Great Britain U.S.S.R.
U.S. Program Medicare Kaiser Health Plan Medicaid Indian Health Service
Medical Care Organization, School of Public Health, University of Michigan, Ann Arbor. This paper, submitted to the Journal in December 1976, was revised and accepted for publication January 15, 1977.
AJPH May, 1977, Vol.67, No.5
COMMENTARY
The only countries in the world that have so far developed for their total population a predominantly organized pattern for delivery of ambulatory health services, combined with general revenue financing, are the socialist nations. In all countries, military personnel are served by such systems. Otherwise, the United States has applied this type of system only to certain economically depressed populations, such as American Indians or impoverished city dwellers served by "neighborhood health centers." Even veterans, who are entitled to certain inpatient services in highly organized hospitals, get much of the ambulatory care (to which they are statutorily entitled) through the "hometown program," using private doctors. The above relationships are not accidental. In all the non-socialist or capitalist countries the use of general revenues, as the initial basis of financing a health care program, has only been applied to limited categorical populations, for whom the allocations may be reduced at any time. (We emphasize "initial" because the dynamics change after two or three decades of experience-see below.) In industrialized capitalist countries everywhere, the initial strategy for broad population coverage has been social insurance or social security financing. About 80 nations throughout the world, both industrialized and developing, have applied this strategy (although in developing countries, population coverage of social insurance is typically restricted to industrial workers). The reasons for this world-wide strategy are clear. It has been largely because of the serious political hazards of the general revenue approach-its great vulnerability to major reductions in funding-that the social security approach has been so widely applied. This strategy has been supported not only by conservative parties, which launched it in 19th century Europe, but also by most left-wing political parties over the last 50 years. The rationale boils down to political realism and economic stability. In free market parliamentary democracies, enactment of a new system of personal health service for all or even most of a national population, through general revenue financing, has simply not been politically feasible. Such financing has been acceptable for the poor (or for the mentally ill) not only because of their marginal status, but also because the funds could be frugally allotted and reduced at will-as, indeed, they usually are. The social insurance mechanism, on the other hand, has everywhere been contrasted to charity and "handouts"; everyone "pays his own way" and earns entitlement to benefits (medical or pensions or other) as a right. This concept has been politically acceptable to nearly all parties in capitalist nations. The United States in the 1970s is no
exception. Even more important is the second reason-stability. Because of the separate status of social security funds, outside the general national treasury, they have everywhere acquired an immunity from political or ministerial inroads. This has applied to the Trust Funds of the U.S. Social Security System, no less than to similar social insurance funds in nations throughout the world. As a result, the benefits payable from these funds have been remarkably assured over the years. AJPH May, 1977, Vol. 67, No. 5
United States Experience For those skeptical of the relevance of this reasoning to the United States, compare the experience of our Medicare and Medicaid programs over just their first 12 years. In both programs, of course, there has been waste and abuse associated with the private fee-for-service pattern of delivery and remuneration. Nevertheless, the Medicare program, based on social security, has had enlargement of its scope. The population covered has been expanded from the aged to include the permanently disabled and persons with severe kidney disease. As a result of both the 1967 and the 1972 amendments, benefits have also been somewhat expanded. When a conservative President (Gerald Ford) proposed a reduction in benefits to Medicare beneficiaries, the idea was ignored by Congress. By contrast, the Medicaid program-financed from federal and state general revenues-has suffered repeated cutbacks. The provisions of the original Act, which required broadening the scope of care under the state plans and liberalizing eligibility, were first postponed and then eliminated. Entitlement to coverage for the medically indigent was restricted. Although the federal government has increased the list of mandated services, many states-under the pressures of financial stringency-have imposed various limits on mandated services and have reduced or eliminated optional ones. The political likelihood of a universal health care system being enacted under general revenue support is extremely remote in America today. But even if, by some political twist, a program with modest coverage or benefits-e.g. a national service for children or for general hospital care-were legislated under general revenue support, one could soon expect the type of scuttling familiar under Medicaid. Regardless of the patterns of delivery, costs would inevitably rise and the voices of conservatism would call for "economies". By legislation or regulation, benefits and coverage would be reduced to save government funds. The introduction of a means test would soon follow. "Why should the taxpayer's money be used," we would hear "for those who can well afford to pay for their medical care?" If a salaried, organized system of delivery were embodied in the program, private practice would still remain. As in Chile, an increasing proportion of people, dissatisfied with a pinchpenny and congested public system, would resort to the private market. The more that demands increased in the private sector, the more the public sector would be deprived of resources. As the vicious cycle continued, the public system would become increasingly concentrated on the poor who could not afford private care.
Evolution of Social Security This sequence has not occurred in countries that initiated their national programs of health service through the social security approach-even when they later shifted to general revenue support. Thus, in Great Britain, National Health Insurance for manual workers was started in 1911. Benefits were limited to general practitioner service and 463
COMMENTARY
drugs, since most hospital and specialist care for this social class were available in public or charitable institutions at little or no charge. It took 37 years of experience with this program-and a World War against Fascism-to pave the way in 1948 for the British National Health Service, supported predominantly by general revenues. Even so, 15-20 per cent of NHS support is still derived from social insurance contributions, and general practitioners remain in private practice (paid about one-half by capitation and one-half by fees). In New Zealand, National Health Insurance covering everyone for comprehensive benefits started in 1939. After 31 years, in 1970, financing was shifted to general revenues, but general practitioners, as in Great Britain, remain in private practice and are paid on a fee-for-service basis. Norway's voluntary health insurance, enacted in 1911, had reached coverage of about 70 per cent of the population in 1956, when it was made mandatory to achieve universal coverage. After 16 years, in 1972, support was shifted to general revenues. These and other national evolutions suggest strongly that, after many years of social insurance experience, the concept of health care as a right becomes so firmly established that no political party would think of eliminating or even reducing it. At this point, the support can be and often is shifted to general revenues without danger to the program. It is worth recalling also that even in the Soviet Union, the world's first socialist nation, the concept of stability in the social security mechanism-protection of the funds from use for other purposes-was initially recognized. Although a system of organized health care delivery, through government-employed physicians working in public facilities, was established soon after the Revolution of 1917, the financing of services for city dwellers was through an earmarked social security fund. Not until 1937-20 years later-was the urban health care system combined with the rural and the financing shifted to the general government budget. Within health care systems financed by social insurance, moreover, it is faulty to regard individualistic patterns of delivery and remuneration as inevitable. Combination (2) defined earlier is illustrated not only by Israel, but also by most Latin American countries and about 20 others. It is true that for out-of-hospital ambulatory care in Western European countries (also in Canada, Australia, New Zealand, and Japan), private delivery initially prevailed. In fact, health insurance has even fortified private practice in the early years. But in time, pressures for more organized and economical delivery patterns soon increase. Thus, even in individualistic France, hundreds of health centers with teams of personnel have been organized through stimulation of the social security system. In Great Britain, the majority of previously solo private general practitioners are now in small groups, and about 20 per cent are in governmental health centers with teams of allied health workers. Canada, the Scandinavian countries, New Zealand, and Australia are all establishing health centers within the framework of their health insurance systems. In the developing countries, the introduction of social insurance for medical care has nearly always been through 464
highly organized networks of health centers and hospitals, staffed entirely by salaried doctors and allied personnel. This is the pattern, as noted, in Israel, Latin America, and many other countries. In fact, taking a world view, about half the nations using social security financing have an organized delivery pattern, with salaried personnel working in public facilities owned and controlled by the health insurance system. This combination of organized delivery with insurance financing in the less developed nations has resulted from the obvious need for economy in these countries. Yet, as noted above, the same pressures for economy and efficiency are also leading to increasingly organized service patterns in the more affluent industrialized countries.
Implicationsfor U.S. Policy In the light of this world-wide experience, as well as the lessons of public medical care programs in the United States, the wisdom of initiating a national health care system in America under the social security mechanism should be clear. When the system achieves political stability and is out of danger from financial cutbacks, it can and should be shifted to general revenue financing. Before that time, patterns of organized delivery can and should be promoted within the social security framework. Considering the legislative measures actually before the U.S. Congress, the whole issue of posing general revenue financing versus social insurance financing is vastly over-simplified. The major proposal backed by organized labor and many other groups is the Kennedy-Corman Health Security Bill (H.R. 21 and S.3), which does, in fact, call for financing 50 per cent from general revenues, the balance coming 35 per cent from employers and 15 per cent from employees. It is all-important, however, that the basic level of the health care funding is to be set by the social insurance contributions, since this amount is to be equally matched (hence 50 per cent) by money from general revenues. European experience has shown this strategy to yield fiscal stability that simply does not occur with general revenue financing alone. As for the so-called "regressive" nature of social insurance fund-raising, compared with general revenues (derived from progressive income taxes), this has been a price that labor and socialist parties throughout the world have been more than willing to pay for the substantial advantages reviewed above. Moreover, as social security leaders have long pointed out, the "regressive taxation" argument is, at best, a half-truth. For one thing, the contribution rates are the same regardless of family size; thus (unlike private insurance) large families-usually of lower income-pay less per member. Secondly, up to a ceiling (which in the U.S. will soon be $16,500 per year), contribution rates (shared by employers and workers) are proportional to earnings, and the regressive impact applies mainly to the minority of people earning more than this ceiling. Thirdly and most important, the "regressive" argument focuses only on the payment side and ignores the benefits of social security. The benefit structure in the United States (and most other countries) is slanted heavily in favor of lowAJPH May, 1977, Vol. 67, No. 5
COMMENTARY
income persons; thus contributors of low "premiums" receive relatively greater benefits than they have paid for, while higher contributors receive relatively lesser benefits. This is especially true of health care benefits, which are identical for all persons-under the Kennedy bill, as in the systems of other countries-regardless of the rate of contributions by each individual. Thus, the attainment of a "National Health Service" in the United States requires far greater analysis of the political dynamics in a free market society than appears to have been made by the new advocates of this idea. Such analysis indicates that the path to a fully organized, comprehensive health service, covering everyone and financed by general revenues, is through the enactment first of a politically feasible National Health Insurance program. The KennedyCorman Health Security Bill needs all the support it can get. This bill, furthermore, offers many ways to improve health care delivery patterns. (To assume, as some do, that a more radical proposal helps the Kennedy-Corman Bill, by showing
I
it to be "moderate", is dangerous; just as likely is the opposite boomerang effect, in which Health Security becomes cast as the insidious entry to fully "socialized medicine.") It would be regrettable if the advocacy of an immediate National Health Service, aside from its naivete, should lend strength to the many conservative forces opposing social security financing of health care for other reasons. History has too many stories of progress obstructed by divisiveness among the proponents of social change. One may hope that, with the prospect of National Health Insurance in America now brighter than in many years, all progressive groups will join in promoting it.
Editor's Note: Two resolutions of the American Public Health Association addressing the concept of a National Health Service were published in the January 1977 issue of the Journal, pp. 84 and 86. The Journal is not a forum for debating APHA policy. It is a forum for discussing national issues of importance.
Federal Health Expenditures
I
uring 1912 the United States government spent $19,800,086.23 for 'its health departments, bureaus, and all other health activities in its various branches,' This information has just been compiled by the secretary of the treasury in response to a resolution of inquiry introduced by Senator Works of California. The estimate includes not only the Public Health Service, together with the medical and hospital work of the War Department, the Navy Department, the Department ofAgriculture and the Panama Canal sanitary service, but also various bureaus andfunds little known to the public at large. "Among these last may be mentioned the International Sanitary Bureau, the International Office of Public Health, the International Conference of the Red Cross, and the International Congress on Hygiene and Demography-all under the State Department. Under the Department ofJustice come the health activities in connection with the support of United States prisoners, amounting to $39,759.76 and the National Training School for Boys. " The number of officers and employees on the federal pay rolls engaged in public health and medical service is between 15,000 and 16,000." The Survey, March 22, 1913. Public Health Notes, In Am. J. Public Health 3:510, 1913.
AJPH May, 1977, Vol. 67, No.5
465
World-wide Experience If we examine the relationships between the statutory patterns for (a) financing and (b) delivery of health care, that *The Committee for a National Health Service was established in 1976 and can be reached at GPO Box 2125, New York, NY 10001. A1ddress reprint requests to Dr. M. I. Roemer, Professor of Health Services Administration, School of Public Health, University of California, Los Angeles, CA 90024. Dr. Axelrod is Professor of
462
AND
S. J. AXELROD, MD
have developed around the world, we find at least four principal combinations. These may be schematized as follows:
Delivery
Financing Individual (1) (3)
Insurance Revenues
Organized (2) (4)
Only combination (4) corresponds to the National Health Service, as perceived by its advocates. The realities are further complicated by the fact that in many nations-such as Sweden, Great Britain, or Chilethere are combinations of both forms of financing within one health care system. Moreover, there are often different patterns of delivery for hospital and ambulatory services in the same system. Thus in Great Britain's National Health Service, hospital care is delivered through organized arrangements, while ambulatory care is still predominantly on an individualistic basis. In Germany, most in-hospital medical care, though not all, is provided by organized staffs of salaried doctors, with ambulatory care by private doctors paid by fees, and this mixed pattern prevails in many European countries. If we focus, for the sake of clarity, on general physician services for ambulatory care, we find that the above combinations may be illustrated in practice as follows: Pattern (1) (2) (3) (4)
Country France Israel Great Britain U.S.S.R.
U.S. Program Medicare Kaiser Health Plan Medicaid Indian Health Service
Medical Care Organization, School of Public Health, University of Michigan, Ann Arbor. This paper, submitted to the Journal in December 1976, was revised and accepted for publication January 15, 1977.
AJPH May, 1977, Vol.67, No.5
COMMENTARY
The only countries in the world that have so far developed for their total population a predominantly organized pattern for delivery of ambulatory health services, combined with general revenue financing, are the socialist nations. In all countries, military personnel are served by such systems. Otherwise, the United States has applied this type of system only to certain economically depressed populations, such as American Indians or impoverished city dwellers served by "neighborhood health centers." Even veterans, who are entitled to certain inpatient services in highly organized hospitals, get much of the ambulatory care (to which they are statutorily entitled) through the "hometown program," using private doctors. The above relationships are not accidental. In all the non-socialist or capitalist countries the use of general revenues, as the initial basis of financing a health care program, has only been applied to limited categorical populations, for whom the allocations may be reduced at any time. (We emphasize "initial" because the dynamics change after two or three decades of experience-see below.) In industrialized capitalist countries everywhere, the initial strategy for broad population coverage has been social insurance or social security financing. About 80 nations throughout the world, both industrialized and developing, have applied this strategy (although in developing countries, population coverage of social insurance is typically restricted to industrial workers). The reasons for this world-wide strategy are clear. It has been largely because of the serious political hazards of the general revenue approach-its great vulnerability to major reductions in funding-that the social security approach has been so widely applied. This strategy has been supported not only by conservative parties, which launched it in 19th century Europe, but also by most left-wing political parties over the last 50 years. The rationale boils down to political realism and economic stability. In free market parliamentary democracies, enactment of a new system of personal health service for all or even most of a national population, through general revenue financing, has simply not been politically feasible. Such financing has been acceptable for the poor (or for the mentally ill) not only because of their marginal status, but also because the funds could be frugally allotted and reduced at will-as, indeed, they usually are. The social insurance mechanism, on the other hand, has everywhere been contrasted to charity and "handouts"; everyone "pays his own way" and earns entitlement to benefits (medical or pensions or other) as a right. This concept has been politically acceptable to nearly all parties in capitalist nations. The United States in the 1970s is no
exception. Even more important is the second reason-stability. Because of the separate status of social security funds, outside the general national treasury, they have everywhere acquired an immunity from political or ministerial inroads. This has applied to the Trust Funds of the U.S. Social Security System, no less than to similar social insurance funds in nations throughout the world. As a result, the benefits payable from these funds have been remarkably assured over the years. AJPH May, 1977, Vol. 67, No. 5
United States Experience For those skeptical of the relevance of this reasoning to the United States, compare the experience of our Medicare and Medicaid programs over just their first 12 years. In both programs, of course, there has been waste and abuse associated with the private fee-for-service pattern of delivery and remuneration. Nevertheless, the Medicare program, based on social security, has had enlargement of its scope. The population covered has been expanded from the aged to include the permanently disabled and persons with severe kidney disease. As a result of both the 1967 and the 1972 amendments, benefits have also been somewhat expanded. When a conservative President (Gerald Ford) proposed a reduction in benefits to Medicare beneficiaries, the idea was ignored by Congress. By contrast, the Medicaid program-financed from federal and state general revenues-has suffered repeated cutbacks. The provisions of the original Act, which required broadening the scope of care under the state plans and liberalizing eligibility, were first postponed and then eliminated. Entitlement to coverage for the medically indigent was restricted. Although the federal government has increased the list of mandated services, many states-under the pressures of financial stringency-have imposed various limits on mandated services and have reduced or eliminated optional ones. The political likelihood of a universal health care system being enacted under general revenue support is extremely remote in America today. But even if, by some political twist, a program with modest coverage or benefits-e.g. a national service for children or for general hospital care-were legislated under general revenue support, one could soon expect the type of scuttling familiar under Medicaid. Regardless of the patterns of delivery, costs would inevitably rise and the voices of conservatism would call for "economies". By legislation or regulation, benefits and coverage would be reduced to save government funds. The introduction of a means test would soon follow. "Why should the taxpayer's money be used," we would hear "for those who can well afford to pay for their medical care?" If a salaried, organized system of delivery were embodied in the program, private practice would still remain. As in Chile, an increasing proportion of people, dissatisfied with a pinchpenny and congested public system, would resort to the private market. The more that demands increased in the private sector, the more the public sector would be deprived of resources. As the vicious cycle continued, the public system would become increasingly concentrated on the poor who could not afford private care.
Evolution of Social Security This sequence has not occurred in countries that initiated their national programs of health service through the social security approach-even when they later shifted to general revenue support. Thus, in Great Britain, National Health Insurance for manual workers was started in 1911. Benefits were limited to general practitioner service and 463
COMMENTARY
drugs, since most hospital and specialist care for this social class were available in public or charitable institutions at little or no charge. It took 37 years of experience with this program-and a World War against Fascism-to pave the way in 1948 for the British National Health Service, supported predominantly by general revenues. Even so, 15-20 per cent of NHS support is still derived from social insurance contributions, and general practitioners remain in private practice (paid about one-half by capitation and one-half by fees). In New Zealand, National Health Insurance covering everyone for comprehensive benefits started in 1939. After 31 years, in 1970, financing was shifted to general revenues, but general practitioners, as in Great Britain, remain in private practice and are paid on a fee-for-service basis. Norway's voluntary health insurance, enacted in 1911, had reached coverage of about 70 per cent of the population in 1956, when it was made mandatory to achieve universal coverage. After 16 years, in 1972, support was shifted to general revenues. These and other national evolutions suggest strongly that, after many years of social insurance experience, the concept of health care as a right becomes so firmly established that no political party would think of eliminating or even reducing it. At this point, the support can be and often is shifted to general revenues without danger to the program. It is worth recalling also that even in the Soviet Union, the world's first socialist nation, the concept of stability in the social security mechanism-protection of the funds from use for other purposes-was initially recognized. Although a system of organized health care delivery, through government-employed physicians working in public facilities, was established soon after the Revolution of 1917, the financing of services for city dwellers was through an earmarked social security fund. Not until 1937-20 years later-was the urban health care system combined with the rural and the financing shifted to the general government budget. Within health care systems financed by social insurance, moreover, it is faulty to regard individualistic patterns of delivery and remuneration as inevitable. Combination (2) defined earlier is illustrated not only by Israel, but also by most Latin American countries and about 20 others. It is true that for out-of-hospital ambulatory care in Western European countries (also in Canada, Australia, New Zealand, and Japan), private delivery initially prevailed. In fact, health insurance has even fortified private practice in the early years. But in time, pressures for more organized and economical delivery patterns soon increase. Thus, even in individualistic France, hundreds of health centers with teams of personnel have been organized through stimulation of the social security system. In Great Britain, the majority of previously solo private general practitioners are now in small groups, and about 20 per cent are in governmental health centers with teams of allied health workers. Canada, the Scandinavian countries, New Zealand, and Australia are all establishing health centers within the framework of their health insurance systems. In the developing countries, the introduction of social insurance for medical care has nearly always been through 464
highly organized networks of health centers and hospitals, staffed entirely by salaried doctors and allied personnel. This is the pattern, as noted, in Israel, Latin America, and many other countries. In fact, taking a world view, about half the nations using social security financing have an organized delivery pattern, with salaried personnel working in public facilities owned and controlled by the health insurance system. This combination of organized delivery with insurance financing in the less developed nations has resulted from the obvious need for economy in these countries. Yet, as noted above, the same pressures for economy and efficiency are also leading to increasingly organized service patterns in the more affluent industrialized countries.
Implicationsfor U.S. Policy In the light of this world-wide experience, as well as the lessons of public medical care programs in the United States, the wisdom of initiating a national health care system in America under the social security mechanism should be clear. When the system achieves political stability and is out of danger from financial cutbacks, it can and should be shifted to general revenue financing. Before that time, patterns of organized delivery can and should be promoted within the social security framework. Considering the legislative measures actually before the U.S. Congress, the whole issue of posing general revenue financing versus social insurance financing is vastly over-simplified. The major proposal backed by organized labor and many other groups is the Kennedy-Corman Health Security Bill (H.R. 21 and S.3), which does, in fact, call for financing 50 per cent from general revenues, the balance coming 35 per cent from employers and 15 per cent from employees. It is all-important, however, that the basic level of the health care funding is to be set by the social insurance contributions, since this amount is to be equally matched (hence 50 per cent) by money from general revenues. European experience has shown this strategy to yield fiscal stability that simply does not occur with general revenue financing alone. As for the so-called "regressive" nature of social insurance fund-raising, compared with general revenues (derived from progressive income taxes), this has been a price that labor and socialist parties throughout the world have been more than willing to pay for the substantial advantages reviewed above. Moreover, as social security leaders have long pointed out, the "regressive taxation" argument is, at best, a half-truth. For one thing, the contribution rates are the same regardless of family size; thus (unlike private insurance) large families-usually of lower income-pay less per member. Secondly, up to a ceiling (which in the U.S. will soon be $16,500 per year), contribution rates (shared by employers and workers) are proportional to earnings, and the regressive impact applies mainly to the minority of people earning more than this ceiling. Thirdly and most important, the "regressive" argument focuses only on the payment side and ignores the benefits of social security. The benefit structure in the United States (and most other countries) is slanted heavily in favor of lowAJPH May, 1977, Vol. 67, No. 5
COMMENTARY
income persons; thus contributors of low "premiums" receive relatively greater benefits than they have paid for, while higher contributors receive relatively lesser benefits. This is especially true of health care benefits, which are identical for all persons-under the Kennedy bill, as in the systems of other countries-regardless of the rate of contributions by each individual. Thus, the attainment of a "National Health Service" in the United States requires far greater analysis of the political dynamics in a free market society than appears to have been made by the new advocates of this idea. Such analysis indicates that the path to a fully organized, comprehensive health service, covering everyone and financed by general revenues, is through the enactment first of a politically feasible National Health Insurance program. The KennedyCorman Health Security Bill needs all the support it can get. This bill, furthermore, offers many ways to improve health care delivery patterns. (To assume, as some do, that a more radical proposal helps the Kennedy-Corman Bill, by showing
I
it to be "moderate", is dangerous; just as likely is the opposite boomerang effect, in which Health Security becomes cast as the insidious entry to fully "socialized medicine.") It would be regrettable if the advocacy of an immediate National Health Service, aside from its naivete, should lend strength to the many conservative forces opposing social security financing of health care for other reasons. History has too many stories of progress obstructed by divisiveness among the proponents of social change. One may hope that, with the prospect of National Health Insurance in America now brighter than in many years, all progressive groups will join in promoting it.
Editor's Note: Two resolutions of the American Public Health Association addressing the concept of a National Health Service were published in the January 1977 issue of the Journal, pp. 84 and 86. The Journal is not a forum for debating APHA policy. It is a forum for discussing national issues of importance.
Federal Health Expenditures
I
uring 1912 the United States government spent $19,800,086.23 for 'its health departments, bureaus, and all other health activities in its various branches,' This information has just been compiled by the secretary of the treasury in response to a resolution of inquiry introduced by Senator Works of California. The estimate includes not only the Public Health Service, together with the medical and hospital work of the War Department, the Navy Department, the Department ofAgriculture and the Panama Canal sanitary service, but also various bureaus andfunds little known to the public at large. "Among these last may be mentioned the International Sanitary Bureau, the International Office of Public Health, the International Conference of the Red Cross, and the International Congress on Hygiene and Demography-all under the State Department. Under the Department ofJustice come the health activities in connection with the support of United States prisoners, amounting to $39,759.76 and the National Training School for Boys. " The number of officers and employees on the federal pay rolls engaged in public health and medical service is between 15,000 and 16,000." The Survey, March 22, 1913. Public Health Notes, In Am. J. Public Health 3:510, 1913.
AJPH May, 1977, Vol. 67, No.5
465
