Insurance against sickness and disability is a praiseworthy and valuable provision against future contingencies. I am not concerned here to point out inequalities to the insured in the English Insurance Act inherent in the apportionment of a flat rate for all ages, districts and occupations, and for both sexes, irrespective of known or suspected incidence of sickness, nor the difficulties created by continuing the nonlocalized work of friendly societies and other private organizations, and at the same time creating local insurance committees, who furthermore were not organically related to local health authorities, and had no opportunity, therefore, to develop the conceivable potentialities of insurance experience as an aid to public health work. The act in its present form is now generally condemned; and it is significant that the need for its radical reorganization appears to be universally accepted.[10]
Two medical benefits (medical and sanatorium) and a maternity benefit were conferred under the act; but, as they have been administered, it cannot be affirmed that any marked public benefit has accrued; and it is certain that if the same amount of money had been placed in the hands of public health authorities to provide adequate medical aid to those needing it, of the kind most lacking and which they could least afford to obtain, great benefit to the public health would have been secured.
What was given? (1) There was the medical benefit, each insured person being entitled to the services of a medical practitioner of his own choice (a “panel” doctor). The services given were limited by regulation to mean such medical attendance as is “within the ordinary professional competence and skill” of a medical practitioner; and so the treatment given has often been more limited than what is given by the more advanced poor law authorities. The latter can supply hospital treatment and expert assistance when required; under the insurance system no such provision is made. The insured patient is not entitled to surgical operations when needed, except of the simplest character; treatment of eye, ear, nose and teeth conditions is commonly excluded; no appliances are given except a few bandages and simple splints; and there are no facilities for modern scientific laboratory investigation, except those provided gratuitously by public health authorities. Furthermore, by the rules of most friendly societies sickness (monetary) benefit during treatment of illness due to the patient’s misconduct is excluded.
The title of the act—National (Health) Insurance Act—has hitherto proved a misnomer. The panel or contract system of medical treatment of insured persons has done much to continue the obsession of the public with the conception of medical care as consisting of a “visit and a bottle”; and so long as the doctor’s medical work is on the present basis, and he is under the constant temptation, not only to accept more patients on his panel than he can satisfactorily treat and to give each patient on application the mental satisfaction of a “bottle,” but also to be more than lenient in the giving of sickness certificates, it will remain questionable whether on the balance state insurance against sickness does more good than harm. If medical consultants and referees, treatment centres, and hospitals are in the future provided for insured patients, this will mitigate the evils of the panel system; but the present contributions of patients will not purchase this additional provision. All the new money needed, and most of the money needed under present conditions, must continue to be provided by the state and employers of the insured (a form of taxation); and provisions thus made, like the present contributions of the state for insured persons, are in direct contravention of the general principle that government grants being derived from the whole community, should enure to the benefit of the whole community in need of them, and not only to the benefit of a section of it.
About one-third of the total population of Great Britain is included within the terms of the National Insurance Act. If the wives and children of insured men were also included, as has been proposed, over two-thirds of the total population would be embraced in the scheme; but as persons manually employed, but working for themselves—e.g., cotters and hawkers, are encluded, and as persons not manually employed cannot be insured unless their income is below £160 (recently raised to £250), large classes of the population who can ill-afford to pay for their own medical attendance are excluded from the operation of the act, and taxed to pay the benefits of insured persons.
(2) The sanatorium benefit was intended to secure for the insured person special treatment for tuberculosis, while capital sums were provided for the erection of sanatoria and hospitals for consumptives for insured and non-insured alike. Fortunately during the passage of the bill, the provision of these institutions for insured persons was delegated to public health authorities; and as it was already within the power of these authorities to provide such institutions and tuberculosis clinics for the entire population, and as the infection of tuberculosis is no respecter of parliamentary distinctions between insured and non-insured, there was little difficulty in persuading the government to promise half the total approved local expenditure on the treatment of tuberculosis in institutions, whether this was given to insured or non-insured persons. Indeed when local authorities were willing to undertake their share in a complete scheme for the treatment of tuberculosis an insured consumptive person might be regarded even as paying fractionally for his treatment while a non-insured person received such treatment gratuitously.
(3) The maternity benefit, conferring thirty shillings on the wife of an insured person, and an additional thirty shillings if she also is an employed person within the meaning of the act, on the birth of her infant, was perhaps the most popular benefit under the act. The money was given unconditionally, and thus an opportunity was lost of insuring that the benefit should improve maternal and infantile prospects.
Collaterally public health authorities, central and local, were beginning to organize medical and nursing assistance during pregnancy, in confinement and afterwards for the mother, and similar assistance on a large scale for infants and children under five years of age. And there will, I think, be no hesitation in agreeing that the supply of service at this critical period of the mother’s and infant’s life, so as to insure the most satisfactory recovery of parent and the best start in infantile life, is infinitely more important than a money grant.
I cannot pretend to have more than touched on the fringe of the complicated subject of insurance in relation to public health. The inauguration of the act meant an enormous increase in the direct relationship of the medical profession to the state. A great stride in the socialization of medicine was taken. But it was done ill-advisedly; it continued a false and low ideal of isolated general medical practice; it has even been described as a fraud on the insured, in view of the incompleteness of the medical service provided; and it diverted into an unsatisfactory channel the energy and money which were urgently needed for the immense good obtainable by reform of poor law and public health administration, and extension of their medical services. Had the lines indicated by history and experience and by the report of a strong royal commission on the poor law—there was a majority and a minority report, but both agreed in the chief essential points—been followed, England would now possess a nearly completely unified state medical service, instead of standing at the point whence false steps need to be retraced, with a view to a coördinated and simplified medical and public health policy. With the principle of contributory insurance to secure monetary support during illness there can be no quarrel; but in the interest of national efficiency complete medical provision, preventive and curative, must be made by the state, irrespective of insurance, for all in need of it; and the medical practitioners employed in the necessary certification of such insurance work as is continued must, if the insurance is to be satisfactory, be employed under conditions which will render them independent of the favor of the insured, and will enable them to utilize their knowledge of each patient’s case for the needed preventive measures, whether these be concerned with the sanitation of home or factory or workplace, or with personal habits.