You have asked me for an additional memorandum on the program for a proposed citizens' organization in the field of health.
During the past few days, I have given this my full attention. A re-read all the previous memos and discussions, examined
Volume I of the commission report minutely, and did a lot of digging in my files on previous studies in the field of medical
care and public health.
I have come to these roughly defined, but rather basic conclusions:
1 - I think that you and I are going in different directions when we start talking about a citizens' movement. With you,
the emphasis is upon more and more studies and some pilot experimentation; with me, the emphasis is almost entirely upon social
Let me document this. I have before me the abridged transcript of the March 20th meeting in New York with the Rockefeller
people. A reading of that discloses that Lowell Reed and I keep talking in terms of social action. For example, on page one,
Dr. Reed talks of "putting public health pressure on the people". On page four, he says: "As Mike says, Parent-Teacher's
organizations, Women's clubs, etc. lack information on the other side of questions." (As against AMA propaganda)
Opposed to this, you emphasize the virtue of the pristine study. On page four, you talk of this projected organization doing
studies "so carefully and competently that attention would automatically be given without a publicity drive." Sir,
I submit this is sheer nonsense. For example, Lowell Reed headed up a distinguished group which did a superb, carefully annotated
three-volume study of the financial condition of the medical schools. The Reed study seems to add up to a powerful lot of
ammunition for some sort of federal aid to medical education. But did it command attention? No. It had very little impact
upon the Congress and the people, because there were no resources to boil its findings down and take them to the people. When
the AMA moved in to fight federal aid to medical education, it buried the Reed report and other studies under an avalanche
of slogans and pieces of misinformation. I could give you a dozen examples of the same sort of thing.
Then again, on page six you say: "Reports and recommendations (of this new organization) should stand by themselves and
if they support legislation, or if legislation is written to support them, I would be pleased." This is commendable and
gracious noblesse oblige, but has little relation to the bitter reality of battling to get pieces of health legislation through
Congress which is terrified by the AMA.
On several other pages of the transcript, you join Dr. Alan Gregg in expressing alarm that "you would get into tax problems
and support problems if the influencing of legislation becomes any appreciable part of the program."
From my rather lengthy experience with health movements, I find this attitude totally unrealistic. If you are not in some
degree to influence legislation, what in the Hell are you going to do?
Let us analyze the problem. First of all, the commission came out for an expenditure of an additional billion dollars in Federal
money to help solve the most pressing problems in medical care. In order to obtain this money, you have to have enabling legislation
put through the Congress, and I know just how tough this is - the odds are 100 to 1 against you. But if you Commissioners
really meant what you resolved, that you should roll up your sleeves and get citizen support behind your proposals.
Let's take the problem of aid to medical education. The commission report recommends $100 million a year in Federal money
to aid the medical schools. Is this a new proposal? Hardly. In addition to all the studies of medical school financing - they've
now got to the point where they are counting the janitors - you have basic legislation to aid the medical schools before the
Congress since 1946. You have had two voluminous sets of hearings, both of which I commend to you. In the light of this overwhelming
data and testimony, why couldn't you pass a bill to aid the medical schools? The answer is simple - the AMA decided in
the summer of 1949 to reverse its previous position and oppose federal aid to medical education. (The Senate had already passed
the bill unanimously in the spring of 1949.)
Now, that's all there was to it. The AMA moved in and said the bill with Socialistic. No one is doing any appreciable
work contra the AMA. I talked to leading Senator who said to me:
"For the past six months, I have been deluged with letters and wires and visits from doctors in my state telling me this
federal aid to medical education bill will put the final nail in the coffin of private medicine. You're the first person
who has come in here and explain the provisions of the bill to me."
In other words, you don't need another study of the financial plight of the medical schools, however high-blown and fancily
worded that study might be. You need pamphlets, brochures, newspaper and magazine stories, etc. explaining the facts about
the medical school situation. You need forums and regional conferences and hearings devoted to the subject.
The same thing holds for health insurance, you don't need another study of health insurance. The commission came out forthrightly
in favor of $750 million a year in grants-in-aid to the states and to encourage the growth of health insurance. What is being
done to implement that recommendation? You have had the Flanders-Ives Bill in the Congressional hopper since 1949 - the so-called
liberal Republican bill to bring health insurance to low-income groups. Yet for four years there have been no hearings on
this bill. Even in the current Republican administration, Senator Ives can't get hearings on the bill. Why? The AMA doesn't
want hearings on the bill - they have attacked it ever since its introduction.
It all adds up to this - we have studies galore in the field of medical care. If you doubt this, read the "Medical Care
Bookshelf" in the April, 1953 issue of the "American Journal of Public Health." In that 19 page article, Dr. Axelrod
lists hundreds upon hundreds of studies in this field, most of the known only to the technicians. (I was not familiar with
more than 50 per cent of the listings.)
In addition, you have a veritable ferment of long-term studies in the field of medical care by every conceivable kind of organization.
The Health Information Foundation, in addition to spending several hundred thousand dollars on a two-year study of the extent
and quality of present health insurance, is devoting additional monies to other phases of medical care. The Commission on
Financing Hospital Care is winding up a two-year study of every gamut of our hospital problem. The Commission a Chronic Illness
is engaged in a prolonged study of the cost and extent of chronic illness. The AMA and the Association of American Medical
Colleges are about to publish the results of the study of medical school so started back in 1949. The Public Health Service
is launched upon a massive series of studies of health manpower. The first section of the "Health Manpower Source Book",
which is on physicians, came out recently. Additional sourcebooks will cover 18 occupations in the health industry.
Inspired by several comments made by Lowell Reed one rainy Sunday afternoon in Baltimore, I put into the one-page memo which
was written as a statement of objectives for the March 20th meeting a sentence about "concentrating upon health education
and information leading to social action." That's the big lag in this field - the solid information is there, but
no one is bringing it down to the level of the people. You need a Whitaker and Baxter campaign on the side of the Angels for
change. Whitaker and Baxter are skilled technicians - they know how to take the dull, obfuscatory misinformation of Frank
Dickinson and bring it down to the level of simply understood sloganized misinformation. This has never been done on our side
of the fence.
2 - With all the above by way of an inadequate introduction, I to argue the function of this Citizens' organization?
Very simply, it broad objections would be those delineated in the Commission Report, not because the Report is sacrosanct
in and of itself, but because it is the best current summation of progressive thinking in the field of medical care. As a
statement of purpose for a new organization, what could be better than this paragraph from page 3 of the report:
"We set as a goal for this Nation a situation in which adequate health personnel, facilities and organization make comprehensive
health services available for all, with a method of financing to make this care universally accessible . . . We expect to
see a splendid hospital system with every area of the country provided with an adequate number of beds, and the obsolete structures
of the past replaced by new facilities which embody all the modern advances. We seek the expansion of our educational system
so that an adequate number of physicians and all other needed health personnel will be trained, with every qualified boy and
girl having an equal opportunity to enter the professions. We favor continued research into health problems, including the
training of an adequate number of scientific workers and providing them with facilities to carry out their work . . . We believe
it is well within the economic potential of this country to provide itself with the finest system of medical care in the world,
that the American people deserve this and deserve no less."
What are we waiting for? There is a decade of work in that paragraph!
With this as a starting point, you would then have as specific objectives the major chapter recommendations of the commission
a - A major morbidity study, or several pilot ones in selected regions.
b - Mobilization of support for the better financing of medical education.
c - Continuation of the Hill-Burton program. (Again, there've been studies ad infinitum of the shortage of hospital beds,
financing of hospitals, etc. Yet the Hill-Burton Act is being hamstrung by the present Congress, and its future beyond 1955
is highly doubtful. You don't need another study here - you need to mobilize people behind this program.)
d - The difficult job of building up public pressure for the Commission recommendation that federal funds be made available
for pilot demonstrations of regional health services and authorities. A corollary to this is the need of selling these pilot
programs to private Foundations.
e - The major commission recommendation, that a cooperative Federal-State program be established to assist in the financing
of personal health services. In the noble words of Clarence Poe:
"Our democracy will never be complete until every person, rich or poor, high or low, urban or rural, white or black, has
an equal right to adequate hospital and medical care whenever and wherever he makes the same grim battle against ever-menacing
death which sooner or later we must all make."
And yet the Flanders-Ives Bill, which would go a long way toward realizing brother Poe's ideal, languishes in committee.
The above list could be expanded manyfold, but it conveys the general idea. Now, as to implementation. How do we accomplish
the objectives outlined above?
a - You set up an organization, headed by a board of not more than a dozen high-level persons. These people must believe in
the general objectives outlined in this memo, just as the board members of the National Citizens' Commission for the Public
Schools believe in certain defined social aims in re the public schools. That organization, for example, is not hunting objectives
- it knows where it's going. There is no point in getting together a group of disembodied spirits who want to rework the
already over-chewed cud in the field of medical care. We need believers and social actionists.
b - You get a good working staff, with the emphasis upon people skilled in the techniques of communication. Yes, you should
have an M.D. as your medical director, because you need the prestige and technical competence he will bring, but you should
have a large public education and information section.
c - You should have a person skilled in working up forums and regional conferences. If you take these issues to the people,
they will get stirred up and the Congress will hear. But it takes a lot of spadework and skill.
d - You should devote a great deal of attention to long-range education - teaching people how to separate fact from propaganda
in this area. Study manuals should be prepared with both sides of a question put fairly to them.
e - You need a minimal budget of $150,000 a year. I say this is minimal, because $150,000 gives you very little for printed
materials. Actually, a small technical staff and expenses would run you about $100,000 a year, leaving you only $50,000 for
brochures, special studies, forms, etc.
All of the above is somewhat rambling because I don't have the time to blueprint the total operation. However, I think
it will give you my orientation. I think that in the last couple of months we have gotten somewhat away from the simple purpose
of such an organization. In reading over the March 20th transcript of our meeting I say this to you: the National Health Council
has more dynamic purpose than any outlined in that transcript.
I don't want to be misunderstood. I am very fond of the academic life, and one of my great regrets is that I had to give
up teaching College history because I had to make some money. I like nothing better than pouring through cumbrous tomes on
medical care, and I would find it very fascinating to be associated with an organization doing involved technical studies
in this field. But all that is not what we met several times to do. Speaking for myself, I am not interested in an organization
which is afraid to tread in legislative waters. You mentioned over the phone that there was a life work in this kind of organization.
Maybe, but not with the present thinking about it. I don't want to skirt problems, nor do I want to fiddle with vellum-bound
studies while the AMA burns all decent health legislation.
I know this is not by way of being a prospectus, but it's what I felt I ought to put on paper. If you can extract any
ideas from it, fine. I am very interested in seeing your prospectus - please shoot it on me as soon as possible.
Let me now if the June 20th meeting is definite. Maybe we need this one more meeting to resolve or agree not to resolve.