Vol. 68, No. 4
285
Minority Perspective of a National Health Insurance* JAMES D. SHEPPERD, M.D., Assistant ProfJssor, Department of Community Health Practice, Howard University College of Medicine, Washington, D.C.
THERE are at least 23,000,000 black Americans whose health care needs are variously attended. Today, I will examine the question of National Health Insurance (NHI) from the minority viewpoint. The current lack of a national health care financing scheme leaves many Americans outside the mainstream of the available supply of health care. The low socio-economic status of most black Americans makes the cost of health care an additional barrier on top of the problems related to the availability and accessibility of care.1 A recent editorial entitled, "There is More to Health Than Just Paying Bills,"2 in the Journal of American Public Health Association by Dr. Paul B. Cornely, a black public health worker and retired chairman of the Department of Community Health at Howard University, sets the tone for our consideration of National Health Insurance proposals. He observes that most of the money for health goes into hospitals, drugs, m.cdical hardware and intensive care units with the major emphasis on cure. In spite of large expenditures, our health status indicators fail to improve. The most important diseases which have arisen from our affluent way of life and multifacited social problems are not addressed by corrective medicine. A National Health Insurance bill should not do away with treatment and cure, but should put them in proper perspective. The considerative factors of equal or greater importance must be written into a bill, such as, heredity, life-style, nutrition, health education, pollution control, and preventive services. For the vast numbers of black Americans *Presented to the Congressional Black Caucus, September 27, 1974.
receiving benefits from Medicare and Medicaid, the shortcomings of these programs are a frustrating reality. Medicare covers only about 70% of the cost of care for the elderly, -while Medicaid benefits and eligibility vary widely from state to state.3 The abuses by patients and providers of their health insurance programs are well known. These programs have dealt primarily with financing and have made no impact on the maldistribution of health manpower, the high incidence of acute illness, chronic diseases, heart disease, eye defects, or mental retardation among the poor. The program called Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for preventive health care under the Medicaid mandate has not been carried out by the states. For the working poor, inadequate insurance provided by marginal employers too frequently gives a false sense of security. For "day laborers", household workers,4 and migrant farmers there are no employer provided health insurance benefits.5 Since a $600.00 a year health insurance premium would represent 20% or more of their takehome pay, this group (about 10% of urban populations) usually "fall through the cracks"- too poor for private insurance and too "rich" for medicaid. They are thus without any adequate health insurance. The variation in coverage by private insurance companies is well known as anyone who has had to use his health insurance can attest.' The double talk of co-payments and deductibles, exclusions and limitations, or pre-existing conditions, renders many health insurance policies worthless. Congress has been considering NHI proposals for the past several years. Offerings by Senator Kennedy
286
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
and Representative Griffith, Senators Long and Ribicoff, the Nixon Administration, the Mills Kennedy Bill, the Mills "Surprise Bill'', offerings by the AMA and the American Hospital Association are among the most prominent. As legislators and legislative staff members, you have had to study each bill carefully and take a position for or against each or attempt to amend the more acceptable proposals. I will not try to analyze each bill for its strengths or weaknesses for black Americans, but rather establish some principles by which to measure the offerings. We hope that any NHI law will serve the public interest and most especially the needs of black Americans. The positions and the principles are given below. Universality. Anyone living in the United States must be eligible for our NHI benefits, be he citizen, resident alien, or a visitor. It goes without saying that a NHI plan must not let anyone be ruled ineligible. Benefits. Emphasis must be placed on the preventive aspect of health care. Reimbursement of providers for health education, environmental evaluation, diagnostic screening examinations and immunizations is a realistic incentive for an extremely valuable service. NHI must provide the full range of personal medical and dental care services, home and nursing home services, rehabilitation, drugs, appliances and mental health care. The use of these benefits must not be blocked by a series of misleading restrictions, exclusions about pre-existing conditions, etc. Resource Development. NHI must be made to affect the methods of delivery of care to the people, and the development of systems of health services must be stimulated in areas where they are needed. We have learned from the dreary experience of Medicaid and Medicare that financing alone is not a remedy for availability of service. Rural and inner city areas, Indian (Native American) communities and migrant labor camps are generaly without an available adequate health care delivery system. (There are only 43 Indian physicians and 2 dentists;
JULY, 1976
only 6,000 black physicians and 3,000 dentists.) The most effective use must be made of their skills where they are available. The insurance plan must make it financially feasible to deliver care to the millions of Americans residing in underserved areas. Even legislating that physicians and dentists serve in these areas for two years after completing their training will not necessarily make it possible for them to stay there. Health Maintenance Organizations are one system of delivery which may work in some areas,7 but other innovations must also receive help for populations where prepaid health care is not an appropriate model of delivery. There is great concern among black consumers and providers about the applicability of the HMO concept in their communities. The lack of manpower, technology, financing, and technical know-how for operating large risky health care businesses are frequently stated problems. More efficient use of health manpower and technology must be stimulated. Physicians and dentists must learn to manage effective health care teams. Acceptable provider roles in underserved areas might be radically different from those in well-served areas. The use of our information processing, communication, and education capabilities must be developed for remote and urban populations. The idea that people can take a greater role and responsibility for their own care must be developed, utilized and encouraged by NHI incentives and promoted through health education. Minority Americans are further behind in health education than in general education (personal communication).8 Administration. An adequate NHI law must have the power and authority of representative government behind it, if it will successfully provide benefits for Americans and control the cost and quality of care. The experience with private commercial insurance companies has been unsatisfactory. The controls, (such as PSRO) established by the Social Security Act in the administration of medicare and medicaid insurance, are steps in the right direction but will require further development and support.
Vol. 68, No. 4
National Health Insurance
The technology for real assurance of quality health care services does not exist as of yet. Although the problems have long been recognized and great efforts expended, we have not progressed much beyond examining records after the case is closed and giving periodic tests to providers of care.9 The cost control system devised by the French National Health Program provides a model which might be adopted by the United States.10 It calls for a strong National Health Insurance Commission with authority to set negotiated fees with the medical and dental associations. It places physicians and dentists under contract to provide an acceptable standard of service. It has achieved control and the cooperation of the providers by a) bringing them into the rule-making process without final authority and b) making the system of controls beneficial to them by making fees stable and uniform. Although there have been holdouts by providers, there have been no disruptions of services during prolonged negotiations (up to six months). The experience of the states in administering the Medicaid program for the poor and disabled has also been most unsatisfactory. Wide variations in the benefits offered by the states have been allowed to continue by the Federal government. The programs mandated by law, such as EPSDT, have not been implemented by most states for a variety of reasons. Again, the poor consumers have not been served by a law designed to improve and maintain their health status. Blacks have suffered inordinately from the poor cooperation given by state Medicaid administrators. Programs for the poor such as Neighborhood Health Centers have been unable to negotiate for their reimbursement. Black private practitioners have had difficulty in getting paid for services rendered, sometimes refusing to accept Medicaid contracts with their state. My recommendation is that the state governments not be involved in the administration of NHI, rather regional offices of the Social Security Administration be made responsible. The NHI or SSA may wish to contract with private insurance companies as carriers as is now done with
287
Medicare, which is fine as long as NHI/SSA remains the final authority. Financing. About $100 billion per year is spent by the health industry in the United States. About one third of this expenditure is now Federal, state, and local money and two thirds is private insurance and out-of-pocket expenses. With NHI this ratio will reverse so that at least two thirds of this money will be funds that pass through the Federal treasury. Much of this money should be collected in the form of employer and employee payroll tax as is the case today with social security retirement and disability benefits. There appears to be no way to avoid additional federal taxes earmarked to support the NHI program. A formula must be devised to prevent such a tax from being regressive. However, these taxes must also automaticaly adjust to the economy. Various financing schemes have been proposed, most of which call for large employer contributions (up to 75% of premium cost), employee contributions, an increase in social security withholding (regressive), and general revenue contributions. The latter sources finance the unemployed and disabled. The formula w&hich provides for equitable and automatic financing is satisfactory. The matter of deductibles and co-insurance is important. A recently released study by the Rand Corporation suggested that the lack of these extra payments by patients would result in an uncontrolled exponential increase in the utilization of ambulatory services.11 While I doubt the conclusions reached by this study, I support the concept of reasonable copayments. Deductibles should be eliminated as an unwarranted administrative burden. The financial contribution of deductibles is, in my mind, not sufficient to justify its use. Co-payments, on the other hand, serve to involve patients in their own care, reminding them of their purchase of a valuable service. The fiscal operation must rest on prospective annual budgets for the support and compensation of those who provide health care services in order to rationalize planning and contain costs. Accountability. This program must establish standards and assure public account-
288
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
ability of program operation and performance. We have all heard the horror stories about abuses of the Medicaid and Medicare programs, much of which has involved black patients. A knowledgeable public with higher expectations of the health care delivery system will make accountability possible.
JULY, 1976
sources and availability of services. 5. Be administered for maximum benefit to the consumer and provider. 6. Be accountable to the public. 7. Represent the interest of the consumer.
Responding to the special interests of blacks will, in all likelihood, result in the greater benefit to all Americans.
SUMMARY
These six major items represent a perspective for viewing a NHI proposal. In addition to an adequate financing bill, matters of policy determination and implementation are important. The representation of the minority consumer and provider viewpoints at this level will make a worthy NHI bill a workable instrument to address our health needs. Black consumers and providers must take part in the decision-making process at all levels. There is no question about whether blacks represent a large and special group with special problems which must be addressed. NHI must take cognizance of this group and provide the means to alleviate the health problems unique to this group. In sum, National Health Insurance proposals are now the first order of business for the legislative branch of government. In order that NHI answer the health problems of blacks, a bill must: 1. Be universal for all American residents. 2. Have broad benefits with emphasis on preventive care and cover routine and catastrophic illness. 3. Be equably financed. 4. Promote the development of health care delivery re-
LITERATURE CITED
1. FALK, I. S. National Health Insurance: A Review of Policies and Proposals. Duke University Law School., 35:670, 1970. 2. CORNELY, P. B. There is More to Health Than Just Paying Bills (Editorial), J. Amer. Pub. Health Assoc., 64:845, 1974. 3. FEIN, R. The New National Policy, New EngI. J. Med., 290:37, 1974. 4. National Association of Household Workers, Inc., Silver Spring, Maryland. 5. SOMMERS, H. H. and R. ANNE. Doctors, Patients and Health Insurance. Brookings Institutions, Washington, D.C. 1961, p.518. 6. FALK, I. S. National Health Insurance: A Review of Policies and Proposals. Duke University Law School., 35:671, 1970. 7. Health Maintenance Organization Assistance Act of 1973. (P.L. 93-222). 8. ROBERTSON, W., Health Educator. Howard University College of Medicine, Washington, D.C. 20059. (Personal communication). 9. Committee on the Cost of Medical Care. Publication #5. 1932. Roanoke Rapids (20) and Union Health Services (19). 10. LORENSEN, L. C. Journal of International Health Services. Vol. 4, No. 1, 1974, pp. 49-57. 11. NEWHOUSE, J. P. et al. Policy Options and Impact of National Health Insurance. New Engl. J. Med., 290:1345, 1974.
(Bornheimer and Havwood from Dage 314) 12. LINDSAY, JR., J. and J. C. MESHEL, and R. 56:1443-1444, 1963. H. PATTERSON. The Cardiovascular Manifes17. FODOR, J. and W. E. MIALL, K. L. STANtations of Sickle Cell Disease. Arch. Int. Med., DARD, Z. FEJFAR, and K. L. STUART, 133:643-651, 1974. Myocardial Disease in a Rural Population in 13. GREEN, R. L. and R. G. HUNTSMAN, and Jamaica. Bull. W.H.O., 31:321-325, 1964. G. R. SERJEANT. Sickle Cell Altitude. Brit. 18. ROSE, G. A. The Diagnosis of Ischemic Heart Med. J., 4:593-594, 1971. Pain and Intermittent Claudication in Field Sur14. JONES, S. R. and R. A. BINDER, and E. M. veys. Bull. W.H.O., 27:645-658, 1962. DNOWHO, JR. Sudden Death in Sickle Cell 19. MOTULSKY, A. G. Frequency of Sickling DisTrait. New Engl. J. Med., 282:323-325, 1970. orders in U.S. Blacks. New Engl. J. Med., 15. RUBLER, S. and R. A. FLEISCHER. Sickle 288:31, 1973. Cell States and Cardiomyopathy. Amer. Jour. 20. SCHNEIDER, R. G. Incidence of Hb C Trait in Cardiology, 19:867-873, 1967. 505 Normal Negroes: A Family with Homo16. BRINSFIELD, G. and F. K. EDWARDS, and zygous Hb C and Sickle-cell Trait Union. Jour. W. L. WATKINS. Sickle Cell Trait and AbnorLab. Clin. Med., 44:133, 1954. mal Cardiovascular Findings. South. Med. Jour.,
285
Minority Perspective of a National Health Insurance* JAMES D. SHEPPERD, M.D., Assistant ProfJssor, Department of Community Health Practice, Howard University College of Medicine, Washington, D.C.
THERE are at least 23,000,000 black Americans whose health care needs are variously attended. Today, I will examine the question of National Health Insurance (NHI) from the minority viewpoint. The current lack of a national health care financing scheme leaves many Americans outside the mainstream of the available supply of health care. The low socio-economic status of most black Americans makes the cost of health care an additional barrier on top of the problems related to the availability and accessibility of care.1 A recent editorial entitled, "There is More to Health Than Just Paying Bills,"2 in the Journal of American Public Health Association by Dr. Paul B. Cornely, a black public health worker and retired chairman of the Department of Community Health at Howard University, sets the tone for our consideration of National Health Insurance proposals. He observes that most of the money for health goes into hospitals, drugs, m.cdical hardware and intensive care units with the major emphasis on cure. In spite of large expenditures, our health status indicators fail to improve. The most important diseases which have arisen from our affluent way of life and multifacited social problems are not addressed by corrective medicine. A National Health Insurance bill should not do away with treatment and cure, but should put them in proper perspective. The considerative factors of equal or greater importance must be written into a bill, such as, heredity, life-style, nutrition, health education, pollution control, and preventive services. For the vast numbers of black Americans *Presented to the Congressional Black Caucus, September 27, 1974.
receiving benefits from Medicare and Medicaid, the shortcomings of these programs are a frustrating reality. Medicare covers only about 70% of the cost of care for the elderly, -while Medicaid benefits and eligibility vary widely from state to state.3 The abuses by patients and providers of their health insurance programs are well known. These programs have dealt primarily with financing and have made no impact on the maldistribution of health manpower, the high incidence of acute illness, chronic diseases, heart disease, eye defects, or mental retardation among the poor. The program called Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for preventive health care under the Medicaid mandate has not been carried out by the states. For the working poor, inadequate insurance provided by marginal employers too frequently gives a false sense of security. For "day laborers", household workers,4 and migrant farmers there are no employer provided health insurance benefits.5 Since a $600.00 a year health insurance premium would represent 20% or more of their takehome pay, this group (about 10% of urban populations) usually "fall through the cracks"- too poor for private insurance and too "rich" for medicaid. They are thus without any adequate health insurance. The variation in coverage by private insurance companies is well known as anyone who has had to use his health insurance can attest.' The double talk of co-payments and deductibles, exclusions and limitations, or pre-existing conditions, renders many health insurance policies worthless. Congress has been considering NHI proposals for the past several years. Offerings by Senator Kennedy
286
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
and Representative Griffith, Senators Long and Ribicoff, the Nixon Administration, the Mills Kennedy Bill, the Mills "Surprise Bill'', offerings by the AMA and the American Hospital Association are among the most prominent. As legislators and legislative staff members, you have had to study each bill carefully and take a position for or against each or attempt to amend the more acceptable proposals. I will not try to analyze each bill for its strengths or weaknesses for black Americans, but rather establish some principles by which to measure the offerings. We hope that any NHI law will serve the public interest and most especially the needs of black Americans. The positions and the principles are given below. Universality. Anyone living in the United States must be eligible for our NHI benefits, be he citizen, resident alien, or a visitor. It goes without saying that a NHI plan must not let anyone be ruled ineligible. Benefits. Emphasis must be placed on the preventive aspect of health care. Reimbursement of providers for health education, environmental evaluation, diagnostic screening examinations and immunizations is a realistic incentive for an extremely valuable service. NHI must provide the full range of personal medical and dental care services, home and nursing home services, rehabilitation, drugs, appliances and mental health care. The use of these benefits must not be blocked by a series of misleading restrictions, exclusions about pre-existing conditions, etc. Resource Development. NHI must be made to affect the methods of delivery of care to the people, and the development of systems of health services must be stimulated in areas where they are needed. We have learned from the dreary experience of Medicaid and Medicare that financing alone is not a remedy for availability of service. Rural and inner city areas, Indian (Native American) communities and migrant labor camps are generaly without an available adequate health care delivery system. (There are only 43 Indian physicians and 2 dentists;
JULY, 1976
only 6,000 black physicians and 3,000 dentists.) The most effective use must be made of their skills where they are available. The insurance plan must make it financially feasible to deliver care to the millions of Americans residing in underserved areas. Even legislating that physicians and dentists serve in these areas for two years after completing their training will not necessarily make it possible for them to stay there. Health Maintenance Organizations are one system of delivery which may work in some areas,7 but other innovations must also receive help for populations where prepaid health care is not an appropriate model of delivery. There is great concern among black consumers and providers about the applicability of the HMO concept in their communities. The lack of manpower, technology, financing, and technical know-how for operating large risky health care businesses are frequently stated problems. More efficient use of health manpower and technology must be stimulated. Physicians and dentists must learn to manage effective health care teams. Acceptable provider roles in underserved areas might be radically different from those in well-served areas. The use of our information processing, communication, and education capabilities must be developed for remote and urban populations. The idea that people can take a greater role and responsibility for their own care must be developed, utilized and encouraged by NHI incentives and promoted through health education. Minority Americans are further behind in health education than in general education (personal communication).8 Administration. An adequate NHI law must have the power and authority of representative government behind it, if it will successfully provide benefits for Americans and control the cost and quality of care. The experience with private commercial insurance companies has been unsatisfactory. The controls, (such as PSRO) established by the Social Security Act in the administration of medicare and medicaid insurance, are steps in the right direction but will require further development and support.
Vol. 68, No. 4
National Health Insurance
The technology for real assurance of quality health care services does not exist as of yet. Although the problems have long been recognized and great efforts expended, we have not progressed much beyond examining records after the case is closed and giving periodic tests to providers of care.9 The cost control system devised by the French National Health Program provides a model which might be adopted by the United States.10 It calls for a strong National Health Insurance Commission with authority to set negotiated fees with the medical and dental associations. It places physicians and dentists under contract to provide an acceptable standard of service. It has achieved control and the cooperation of the providers by a) bringing them into the rule-making process without final authority and b) making the system of controls beneficial to them by making fees stable and uniform. Although there have been holdouts by providers, there have been no disruptions of services during prolonged negotiations (up to six months). The experience of the states in administering the Medicaid program for the poor and disabled has also been most unsatisfactory. Wide variations in the benefits offered by the states have been allowed to continue by the Federal government. The programs mandated by law, such as EPSDT, have not been implemented by most states for a variety of reasons. Again, the poor consumers have not been served by a law designed to improve and maintain their health status. Blacks have suffered inordinately from the poor cooperation given by state Medicaid administrators. Programs for the poor such as Neighborhood Health Centers have been unable to negotiate for their reimbursement. Black private practitioners have had difficulty in getting paid for services rendered, sometimes refusing to accept Medicaid contracts with their state. My recommendation is that the state governments not be involved in the administration of NHI, rather regional offices of the Social Security Administration be made responsible. The NHI or SSA may wish to contract with private insurance companies as carriers as is now done with
287
Medicare, which is fine as long as NHI/SSA remains the final authority. Financing. About $100 billion per year is spent by the health industry in the United States. About one third of this expenditure is now Federal, state, and local money and two thirds is private insurance and out-of-pocket expenses. With NHI this ratio will reverse so that at least two thirds of this money will be funds that pass through the Federal treasury. Much of this money should be collected in the form of employer and employee payroll tax as is the case today with social security retirement and disability benefits. There appears to be no way to avoid additional federal taxes earmarked to support the NHI program. A formula must be devised to prevent such a tax from being regressive. However, these taxes must also automaticaly adjust to the economy. Various financing schemes have been proposed, most of which call for large employer contributions (up to 75% of premium cost), employee contributions, an increase in social security withholding (regressive), and general revenue contributions. The latter sources finance the unemployed and disabled. The formula w&hich provides for equitable and automatic financing is satisfactory. The matter of deductibles and co-insurance is important. A recently released study by the Rand Corporation suggested that the lack of these extra payments by patients would result in an uncontrolled exponential increase in the utilization of ambulatory services.11 While I doubt the conclusions reached by this study, I support the concept of reasonable copayments. Deductibles should be eliminated as an unwarranted administrative burden. The financial contribution of deductibles is, in my mind, not sufficient to justify its use. Co-payments, on the other hand, serve to involve patients in their own care, reminding them of their purchase of a valuable service. The fiscal operation must rest on prospective annual budgets for the support and compensation of those who provide health care services in order to rationalize planning and contain costs. Accountability. This program must establish standards and assure public account-
288
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
ability of program operation and performance. We have all heard the horror stories about abuses of the Medicaid and Medicare programs, much of which has involved black patients. A knowledgeable public with higher expectations of the health care delivery system will make accountability possible.
JULY, 1976
sources and availability of services. 5. Be administered for maximum benefit to the consumer and provider. 6. Be accountable to the public. 7. Represent the interest of the consumer.
Responding to the special interests of blacks will, in all likelihood, result in the greater benefit to all Americans.
SUMMARY
These six major items represent a perspective for viewing a NHI proposal. In addition to an adequate financing bill, matters of policy determination and implementation are important. The representation of the minority consumer and provider viewpoints at this level will make a worthy NHI bill a workable instrument to address our health needs. Black consumers and providers must take part in the decision-making process at all levels. There is no question about whether blacks represent a large and special group with special problems which must be addressed. NHI must take cognizance of this group and provide the means to alleviate the health problems unique to this group. In sum, National Health Insurance proposals are now the first order of business for the legislative branch of government. In order that NHI answer the health problems of blacks, a bill must: 1. Be universal for all American residents. 2. Have broad benefits with emphasis on preventive care and cover routine and catastrophic illness. 3. Be equably financed. 4. Promote the development of health care delivery re-
LITERATURE CITED
1. FALK, I. S. National Health Insurance: A Review of Policies and Proposals. Duke University Law School., 35:670, 1970. 2. CORNELY, P. B. There is More to Health Than Just Paying Bills (Editorial), J. Amer. Pub. Health Assoc., 64:845, 1974. 3. FEIN, R. The New National Policy, New EngI. J. Med., 290:37, 1974. 4. National Association of Household Workers, Inc., Silver Spring, Maryland. 5. SOMMERS, H. H. and R. ANNE. Doctors, Patients and Health Insurance. Brookings Institutions, Washington, D.C. 1961, p.518. 6. FALK, I. S. National Health Insurance: A Review of Policies and Proposals. Duke University Law School., 35:671, 1970. 7. Health Maintenance Organization Assistance Act of 1973. (P.L. 93-222). 8. ROBERTSON, W., Health Educator. Howard University College of Medicine, Washington, D.C. 20059. (Personal communication). 9. Committee on the Cost of Medical Care. Publication #5. 1932. Roanoke Rapids (20) and Union Health Services (19). 10. LORENSEN, L. C. Journal of International Health Services. Vol. 4, No. 1, 1974, pp. 49-57. 11. NEWHOUSE, J. P. et al. Policy Options and Impact of National Health Insurance. New Engl. J. Med., 290:1345, 1974.
(Bornheimer and Havwood from Dage 314) 12. LINDSAY, JR., J. and J. C. MESHEL, and R. 56:1443-1444, 1963. H. PATTERSON. The Cardiovascular Manifes17. FODOR, J. and W. E. MIALL, K. L. STANtations of Sickle Cell Disease. Arch. Int. Med., DARD, Z. FEJFAR, and K. L. STUART, 133:643-651, 1974. Myocardial Disease in a Rural Population in 13. GREEN, R. L. and R. G. HUNTSMAN, and Jamaica. Bull. W.H.O., 31:321-325, 1964. G. R. SERJEANT. Sickle Cell Altitude. Brit. 18. ROSE, G. A. The Diagnosis of Ischemic Heart Med. J., 4:593-594, 1971. Pain and Intermittent Claudication in Field Sur14. JONES, S. R. and R. A. BINDER, and E. M. veys. Bull. W.H.O., 27:645-658, 1962. DNOWHO, JR. Sudden Death in Sickle Cell 19. MOTULSKY, A. G. Frequency of Sickling DisTrait. New Engl. J. Med., 282:323-325, 1970. orders in U.S. Blacks. New Engl. J. Med., 15. RUBLER, S. and R. A. FLEISCHER. Sickle 288:31, 1973. Cell States and Cardiomyopathy. Amer. Jour. 20. SCHNEIDER, R. G. Incidence of Hb C Trait in Cardiology, 19:867-873, 1967. 505 Normal Negroes: A Family with Homo16. BRINSFIELD, G. and F. K. EDWARDS, and zygous Hb C and Sickle-cell Trait Union. Jour. W. L. WATKINS. Sickle Cell Trait and AbnorLab. Clin. Med., 44:133, 1954. mal Cardiovascular Findings. South. Med. Jour.,
