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pattern confused in its professional and administrative as-
pects, inadequate to present responsibilities, and without
the logic and order fundamental to any effective program
of public welfare.

While there is disagreement in various quarters as to the
adequacy of the medical service now available to the sick
poor, the findings of the recent National Health Inventory
supply plenty of evidence in support of the assertion, long
made by those close to the situation, that the medical needs
of the sick poor are not being met satisfactorily.

If more complete medical service is to be provided for
such part of our "ill-clothed, ill-fed, ill-housed" population
as cannot purchase it for themselves, whose should be the
job ? By what machinery of government should this service
so vast in its mass, so individual in its content be ad-
ministered ?

The quick and easy answer is: "By expanding what we
have. Expand our health departments, our welfare depart-
ments, our hospitals, our public health nursing expand,
expand!" The answer to that is: our present set-up for the
care of the sick poor is so confused in its allocations of
responsibility and authority that immediate expansion suffi-
cient to deal with unmet needs might be an invitation to
chaos if not to collapse.

*'"' <-he fair day is coming not this year or next per-
haps, DUt V coming when government will assume more
re \ sponsibility in this area of human welfare. Facts
must be "ved, the facts of great numbers of people who in
health mar^,^ to ma i nta j n themselves without public
assistance but wnose m ar giri of independence is so narrow
that illness leay es them helpless Their ill ness e s> untreated
because they cat mot pay the bjll) pave fhe way to pro i onged
or permanent d epen dence.

These people do not march fo Washington or demon-

strate at the cit;
though we do n
articulate we
did five years a

hall or picket the health departments. But
ot see or hear them they are curiously in-
now a great deal more about them than we
o, and we know something more about the

ingle that now complicates their problems,
jh certainly to see that much must be done
)repared to administer a program of the

administrative t

We know enou

before we are

size and comple^ demanded by their ne eds & in sickness.

Among the n\ ny tn j n g s tne depression brought to public
attention were the facts about people unab i e to pay for
medical care, f< cts whkh hitherto had been a i most the
exclusive possess, Qn Q { physicians, nurses and social work-
ers. To be sure the Committee on the Costs of Medical
Care, working i^ a per ; od O f pros perity, had spread a lot
of this informal^ Qn the rccor(J) but it took {he depression
to make it vivid jj y pusn i n g on to public aid great numbers
of people who ^ itheTto bad ma i nta i ned themselves and
whose lack of - leeded medica i care had been no one ' s
business but then Qwn

The Federal JU^ney R e i; e f Administration held that
medical care is o e of fhe necessities o f ^ and developed


procedures for implementing this policy through payments
from relief funds to individual physicians, dentists, phar-
macists and nursing associations (but not hospitals) for
services to relief clients. Some of the programs then initi-
ated have been continued and developed with local funds,
but in many localities medical care is back where it was
before. FERA brought out not only the need of the eco-
nomically disfranchised for medical treatment but the lack
of orderly organization for rendering it.

Further light on the problem has been supplied by the
National Health Inventory which, as said in Survey Mid-
monthly [February 1938, page 54] gave the nation "its
first life-sized answers" to such questions as: "Who and how
many people in the United States are sick at a given time ?
What is the nature of their disability? How much medical
and nursing care do they receive? How do the amounts of
total sickness and of care received relate to economic con-
ditions ?"

It is not possible to review here the exhaustive facts and
figures of the inventory. The findings, substantiating those
of earlier, less extensive' studies show that families with an
annual income of less than $1000 probably a third of our
entire population are sick oftener, that their illnesses last
longer and that they have less medical and nursing care
than their better-to-do neighbors.

In any discussion of means for meeting the needs of per-
sons unable to pay for medical care three questions arise :

1. Should tax funds provide medical care?

2. Who should be eligible for tax-supported medical care?

3. How should tax-supported medical care be administered?

The first question, long and vigorously debated up and
down the land, seems academic considering that tax funds
always have provided medical care in continually widening
areas of practice. Along with the poor laws that plague
us, we inherited from good Queen Bess the principle that,
as Surgeon General Thomas Parran said at the recent
Conference on Better Care of Mothers and Babies, "medi-
cal care of the indigent is a responsibility of society equal
to the responsibility of providing them with food, shelter
and clothing."

THE history of public medical care is one of slow and
continuous extension. It has been estimated that local,
state and federal jurisdictions expend some $500 million
annually for the prevention of diseases and the medical
care of the needy. The federal government alone expends
something like $100 million a year for these purposes. In
addition to its preventive program, government has as-
sumed almost complete responsibility for the hospital care
of tuberculosis and of contagious and mental disease not
only for the indigent but for the general population. Some
local jurisdictions also provide considerable service for acute
illness through city or county hospitals, and through pay-
ments to voluntary hospitals, nursing associations and physi-
cians. Many communities, however, still depend for such
service upon privately supported agencies hospitals, clin-
ics and nursing associations and upon the medical profes-
sion which, with its tradition of serving the sick poor with-


lout pa\, continues to provide literally millions of dollars
I worth of care annually to persons unable to pay for it.
I But the voluntary agencies and the medical profession have
I been hard hit by the depression and no longer can afford
I to carry this growing burden.

Thus the answer to the question, "Should tax funds pro-
vide- medical care?" is, "They already are doing so." The
t principle is established, but the practice is very uneven.

The answer to the second question, "Who should be

| eligible ?" is by no means simple, for it is encrusted with

[traditions and hung with varying interpretations and prac-

Admitting the eligibility of the legally indigent (those

b dependent on public aid for food and shelter) there re-

, mains the great mass of borderliners, those receiving such

[public aid as WPA employment and assistance under the

Asocial security services, and those not on relief but unable

to pay for their own care in sickness.

To discover the prevailing policy of public welfare de-
partments toward these borderliners the American Public
['Welfare Association recently gathered information from
fifty large counties and cities over the country. Eight of
these jurisdictions reported that the otherwise self-support-
Ijing are not eligible for tax-supported medical services; five
that special types of cases or categories, such as "emer-
gencies," and WPA employes are eligible; ten that the
'Otherwise self-supporting may be eligible for hospital
Sand/or out-patient treatment after financial investigation ;
twenty-seven that they may be eligible for any type of ser-
vice after such investigation. Varying practice in this last
group is indicated by such replies as: "We accept them on
U budgetary deficiency basis, with rather liberal interpre-
tation." . . . "Very selective basis, very few such cases."


Public Health

Collegt of Physicians and Surgeons, Columbia University

pleton. 1913.

Because it remains the only comprehensive textbook in
English describing the preventable diseases and the administra-
tive measures applicable to their control.

pleton. 1914.

Because the wisdom and experience of the clinician was
here applied to a whole new world of preventable disease.

Motby. 1922.

Because the natural history of communicable diseases as
here presented has influenced public health services through-
out the United States.

en 11 ii HYGIENE, by S. Josephine Baker. Harper. 1925.

Because the survival of mothers and children in this country
has been made more probable and happier through this book.

Newiholme. P. S. King and Son. 1927.

Because it has enlarged the imagination of every health

1937 BOOK

SHADOW ON THE LAND SYPHILIS, by Thoma* I'arran. Rev-
nil. 1937.

Because it is a potent weapon for the medical profession
and the layman in the attack on "the next great plague to go."

It is clear that in most places eligibility turns on inves-
tigation of ability to pay. The practical question then arises,
who shall be responsible for this investigation? The prac-
tical answer is, the agency that pays the bill the hospital
that admits the patient to its own free service, or the pub-
lic department that refers the patient to the hospital as a
public charge. In practice, the line of this responsibility is
apt to become confused, following local habits rather than
definite policies. This is aggravated of course where gov-
ernmental responsibility for actual service or for payment
for service is split up arbitrarily between departments.

HOSPITALS and the medical profession have had long
experience in defining eligibility for free care, and
have made many studies of the subject, most of them aimed
at determining the extent of "clinic abuse." In 1928 the
Out-Patient Committee of the American Hospital Associa-
tion summarized outstanding studies of twenty-five years
and defined social and financial factors involved in decisions
as to patients' ability or inability to pay.

Public welfare officials have much less recorded experi-
ence to guide them. A good many of them, struggling with
new and complicated responsibilities, pressed by the obvi-
ous need for medical services and by restricted budgets, find
themselves in a sea of difficulties, lacking definite princi-
ples on how to determine eligibility, and with their author-
ity to make decisions sometimes challenged.

A joint committee representing the American Public
Welfare Association and the American Hospital Associ-
ation has been studying the urgent question of eligibility.
It is not attempting to set up standards of eligibility but
to formulate principles under which the authorities of
each jurisdiction, within the framework of state laws and
local ordinances, can develop fair standards for determina-
tion. Its work is not completed, but the committee seems
to be of the opinion that the determination of a patient's
need for medical care is primarily the responsibility of the
medical profession, but that the responsibility for determin-
ing whether he can be given such care at public expense
rests with the public official charged by law with providing
essential services to needy persons.

The committee has approached the subject with the con-
viction that many of the present difficulties need not exist
if the whole plan for admitting patients to tax-supported
medical care is worked out jointly by public welfare offi-
cials, physicians and hospital authorities.

If the answer to who is eligible is foggy in current prac-
tice, the answer to who should administer tax-supported
medical care is completely beclouded. The American Pub-
lic Welfare Association secured a sample of the current
situation from the welfare departments of twenty-seven
states and fifty-four large counties and cities. Many wel-
fare departments reported broad responsibilities for admin-
istering medical services. For example, seven of the states
and twenty-five of the smaller jurisdictions reported their
welfare departments operating medical institutions, mostly
hospitals, as well as administering other medical programs
such as home care by physicians. In another five states and
fifteen communities public welfare agencies were adminis-
tering home care but no institutions.

Health departments, it seems, have less responsibility in
this field. For example, in the localities which reported,
general hospitals are operated by sixteen welfare depart-
ments and by only four health departments; mental hos-
pitals, by fifteen welfare, one health ; tuberculosis hospi-

MAY 1938


tals by thirteen welfare, fourteen health; contagious dis-
ease hospitals by ten welfare, fourteen health. Sixteen cities
reported physicians' home care provided or paid for by wel-
fare departments ; seven by health departments ; three by
emergency relief administrations. Two cities provided the
same type of service through two different departments.

THE further one goes in delving into "who is doing
what" in providing tax-supported medical care the
more evidence is found of overlapping or duplicating au-
thority. Of fifteen reporting states that operate more than
one type of hospital (general, mental, tuberculosis) ten
divide this responsibility between two or more separate de-
partments. In two states three different departments oper-
ate hospitals while a fourth (and in one instance a fifth)
is responsible for payment to voluntary hospitals for the
care of special categories of disease. In one of these states
two additional authorities in each county, acting independ-
ently of any state authority, administer payment to volun-
tary hospitals for general care of the poor. In twenty-one
of the forty reporting cities and counties in which tax funds
provide both general hospital and physicians' home care,
these services are now administered by two different pub-
lic departments.

In spite of all the criss-crossing authority in the re-
porting cities and counties or perhaps because of it a
good many serious gaps exist in the tax-supported services
provided. For example, three cities and counties reported
no tax-supported general hospital service whatever; four-
teen no public provision for the hospitalization of contagi-
ous diseases; six, no home care by physicians; thirteen, no
dental care.

It is not only the lack of facilities for medical care that
plagues welfare officials, but the inadequacy of existing fa-
cilities. Of sixty-six replies by welfare officials to the
APWA's inquiry concerning unmet medical needs, few
indeed reported no inadequacies whether in hospital ser-
vice, institutional care for the chronic sick, medical service
in the home, clinic, dental, preventive or diagnostic ser-
vices ; or in services for special groups such as WPA work-
ers, transients or recipients of social security assistance.
Replies include such phrases as "all pitifully inadequate"
. . . "service especially lacking in rural areas." Eighteen
jurisdictions, for example, reported as "most unsatisfac-
tory" their provision for tuberculosis; fourteen for ven-
ereal disease; and so on down the list to the one commu-
nity that reported provision for Negro unmarried mothers
as its greatest inadequacy.

Many communities long have had machinery for the
participation of the medical professions and public health
authorities in planning the medical programs of the pub-
lic welfare department. FERA rules required it. But the
APWA inquiry showed that at the present time welfare
departments are not making full use of professional ad-
vice. Of twelve state departments reporting responsibilities
for medical care only five had professional advisory com-
mittees; of forty cities and counties, only eighteen. Five of
the twelve states reported physicians in charge of the medi-
cal program. Nineteen of the forty counties and cities re-
ported professional persons in charge fourteen physicians,
three nurses, two medical social workers. The medical
programs in seven reporting states and twenty-one cities
and counties are administered by "laymen." The inquiry
indicates that whatever the general principles of profes-
sional supervision of medical programs, in actual practice

many of the medical services administered by welfare de-
partments are without such supervision.

Although provocative, the birdseye view afforded by the
APWA inquiry into the present administrative set-up
for tax-supported medical care is merely a preliminary
step. The need for a thorough authoritative study is clear-
ly indicated, so that arfter conference among appropriate
groups, principles (but not an exact pattern) of adminis-
trative responsibility may be developed. Such questions
must be considered as:

Should several different governmental departments on each
level (federal, state, local) 'be responsible for administering
medical care, or should it be the responsibility of a single de-
partment on each level?

Should responsibility for both the social and medical treat-
ment of an individual be combined in the welfare depart-
ment? Should both the prevention and treatment of disease be]
combined? Should all three be combined, or should medical
care be quite independent of social treatment and public

Medical care, welfare, and public health have close ties
and there are arguments on the score of continuity of care,
efficiency and economy for the several combinations. Possi-
bly the principles ultimately developed will suggest differ-
ent arrangements according to the size and the nature
urban or rural of the jurisdiction to be served.

This country is not alone in facing problems stemming
from the haphazard development of governmental respon-
sibility for medical care. The recent Report on the British
Health Services, by a group familiarly known as PEP
(Political and Economic Planning), analyzes the diversity
of structure and lack of integration of the British health
and medical services, and in its summary says:

Study is needed not only of the diseases and disabilities of
the human body but of the health services themselves, with
their cancerous growths of redundant institutions and commit-
tees needing drastic surgical treatment.

We also show that the public health services are enormously
hampered by piecemeal and anomalous methods of organiza-
tion which have no justification upon health and administra-
tive grounds and involve waste of resources and increased
suffering or inconveniences to the consumer.

MANY public welfare officials, so deep in the trees that
they can't see the woods, are muddling through
their day-to-day difficulties without much awareness of
how ill-defined are the principles and policies under which
medical care programs operate. But leaders among them,
as among physicians and public health and hospital ad-
ministrators, realize that the house urgently needs to be
put in order. The federal government, and various pro-
fessional organizations such as the American Medical As-
sociation and the American Public Health Association,
have urged integration and coordination of governmental
medical and health services, and the necessity for careful
study of the means by which the general will to cooperate
may be made effective. The trustees of the American Medi-
cal Association, for example, are encouraging state and
county medical societies to assume leadership in securing co-
operation to determine and supply "the prevailing need for
medical and preventive medical services where such may
be insufficient or unavailable." The American Public
Health Association has a special committee to cooperate
with other bodies in "extending public health work to meet
modern needs. ..." The recent Conference on Better



lor Mothers and Babies, called by the U.S. Children's
[Bureau [see Survey Midmonthly, February 1938, page 38]
emphasized planning and coordination of medical programs
(and brought together representatives of nearly a hundred
(national agencies concerned. Most recently, the President's
Interdepartmental Committee to Coordinate Health and
Welfare Activities has released its study, The Need for a
[National Health Program, showing the interrelations
among the major problems and the importance of a gen-
eral coordinated plan of action.

To bring public welfare officials in touch with sources
of aid for their current difficulties, the APVVA has ap-
pointed a physician as liaison officer between its own mem-
tiers and national agencies concerned with the professional

aspects of medical service, such as the U.S. Public Health
Service, the American Medical Association, the American
Dental Association, the American Hospital Association,
the National Organization for Public Health Nursing, the
Children's Bureau and so on. The APWA proposes to
bring the problems of public welfare officials in this area
to the attention of appropriate medical and health agencies
with a view to stimulating studies and joint agreements
on policies and procedures.

"Joint planning" and "coordination of effort" are the
watchwords in the effort to give more adequate service to
persons unable to pay for medical care. All signs point to
the development of more carefully thought out policies and
more orderly procedures.

The Things We Do Together


A^Y man or woman who acknowledges an urge to
make life more worth living, for some of us or for
all of us, finds that he has moved into a mental
neighborhood full of other people who share his sincerity
and conviction, but who are otherwise "as different as their
fingerprints." Any organization coming under the broad
cation of "social welfare" leases space in this com-
Imunity of interests.

In this neighborhood of ideas and purposes there is need
for a wise and economical distribution of energy. We have
all been thinking a good deal about such distribution in the
.past twenty-five years. We have been calling it "community
organization," "social engineering," or plain "planning."

A quarter of a century ago, in Chicago, a handful of
agency executives undertook to fit together the rough edges
nf public and private social agency work into some sort of
community welfare plan. What they got when they finally
saw it all in one piece was an old-fashioned crazy quilt.
iThrrr were whole blocks of patchwork that carried out con-
Distent patterns, such as the federations of settlements and
jday nurseries. There were others arranged in harmonious
colors, such as the Jewish charities. There were dozens of
[unattached squares, triangles and rectangles representing
individual agencies which had to be fitted somewhere into
the big design, and a number of pieces that had been dyed
ne\v colors. Some were faded and some were threadbare.
There were big holes that needed filling in, overlapping
margins and all kinds of discrepancies.

This little group of original planners could have made a
neater job of it if they had started from, scratch, but they
didn't. They used what they had. They matched, pieced,

'mined edges and filled in gaps. They called themselves a
Council of Social Agencies. It was a good name, then
for this early council belonged to the agencies. Its first con-
cern was to prevent duplication and overlapping, promote
cooperation, and supplement individual effort by united

Drop the crazy quilt idea here. It doesn't fit the rest of
this story any better than that original patchwork fits to-
day's idea of welfare planning in a great city. Swing back
to the idea of a neighborhood of ideas and purposes, and
look critically at our title, "Council of Social Agencies."

Might it give the impression that we are an agency-
protective association? If so, we have outgrown it. The
council's direct services to its member agencies, its steady
effort to raise standards of individual work, help plan
specific programs, advise on personnel, budgets and countless
other agency problems, is only a part of its usefulness to the
city of Chicago. The biggest end of our task today is to
bring together the forces in the city concerned with social

Online LibrarySurvey AssociatesSurvey midmonthly : journal of social work (Volume 74) → online text (page 45 of 109)