A Nation Insured

AUTHOR’S PREFACE TO THE THIRD EDITION.

I HAVE written this little book for love, and the Liberal Publication Department are publishing it without profit, in order to spread knowledge of the details of a great measure of legislation which will affect a member or members of nearly every household in the land.

The author appeals to the reader to help him in his task by assisting to circulate this work. Since the first edition was issued, it has unhappily become apparent that there are quarters in which it has been determined to deny fair play to the Act and to create prejudice against it. It is therefore incumbent upon the friends of the Act to meet misrepresentation by making the truth known, and it is hoped that in this book they will find the means of effectively circulating the facts.

The author would be obliged to any reader who would write to him or to the Liberal Publication Department if any error or omission in the work is discovered, or if any expression in it is found to be in any degree misleading, but he cannot enter into correspondence on the Act.

A word in conclusion to those who will be insured under the Act. I should like to be allowed to counsel every worker to get at once into touch with a Friendly Society or Trade Union, and not to wait for the Act to come into operation before deciding what Society to join. Information as to Trade Unions or Friendly Societies can usually be obtained from friends, neighbours, or work-mates.

A Nation Insured

“An Act to provide for Insurance against Loss of Health and for the Prevention and Cure of Sickness, and for Insurance against Unemployment “—such is the full title of the National Insurance Bill which became law on Saturday, December 16th, 1911. It is a measure designed not only to insure our great working population against sickness, but to organize medical science for the prevention of sickness. It marshals the entire community in aid of the worker who, at whatever age, becomes unfit for work through physical break­down. It is regardful of the poor mother in her hour of need. It lifts the consumptive out of his environment in order to effect cure when cure is possible, and to prevent the spread of one of the worst of diseases. In these phases, as we shall see as we proceed, the Act is a measure preventive at once of sickness and of some phases of unemployment. With regard to the latter, the Act secures maintenance during unemployment in the industries worst visited by irregularity of trade, and, in addition, handsomely subsidises Trade Unions which pay out-of-work benefit to their members.

We have 45,000,000 people and 32,000 doctors, but the doctor­ing is very unfairly distributed amongst us. The means of health are as badly distributed as the national income. Sickness walks with poverty, but one wealthy malade imaginaire can command more medical attendance than a thousand workpeople debilitated by an unhealthy occupation. Probably one-half of our outdoor pauperism is due to the sickness or physical disablement of breadwinners.

If one person is done to death by violence, the nation is stirred to its depths. We pursue the criminal; we exhaust the resources of science to trace him and to bring him to justice. If there is less concern about the yearly slaughter of tens of thousands of innocent victims in the mean streets of our great towns than about a single murderer, it is because there is general lack of realization of the nature and extent of the crimes of our civilization. We have many towns Burnley, Aberdare, Stalybridge, Batley, Longton, to name but a few—where 200 out of each 1000 children born die within twelve months of birth. In the worst quarters of these and other places one in three of the children are slaughtered in infancy. And the wholesale sacrifice of infants is followed by the robbery of a great part of the life of those who survive. If we compare the expectation of life in a poor district with that in a rich district, what do we find? Look at the following figures:

How the Poor Lose Life

At birth a Southwark child has on the average fourteen years less to live than a Hampstead child. Those who survive in Southwark until ten years of age have eight years less to live than the larger proportion of Hampstead children who live to be ten. The small proportion of Southwark males who live to be twenty have nearly eight years less before them than the youths of the same age in Hampstead.

It is not pretended that the National Health Insurance can dispose of these damning facts. As Mr. Lloyd George himself has put it, the remedy must cut deeper. It is urged, however, that we shall never rise to the fu11 realisation of our social responsibility in regard to life and death until we have resolved to make the national health a matter of legislative concern. Social insurance is in part a means of prevention, and it will infallibly stimulate us to the framing of other means of prevention.

Some one has coined the epigram that sickness insurance is “paying a man to be sick instead of preventing his sickness?” It is always difficult to get the whole truth into an epigram, and this one is particularly deficient in its summing up of the subject. In practice it is found that universal compulsory insurance is a very real preventive of sickness and of more than sickness.

In the first place, we have to note that when by means of a State scheme we put at every one’s disposal either the best medical treatment in his own home, or, in special cases, removal to a sanatorium, prevention arises because a workman is no longer

tempted to put off medical treatment indefinitely. Through the postponement of proper treatment, an exceedingly large number of cases become serious, which, if they had been treated in time, would have entailed little trouble or suffering.

In the second place, efficient and timely medical treatment may not only prevent serious sickness, but prevent what is often the result of serious sickness, viz., permanent invalidity and conse­quent incapacity for work. From this point of view, State insurance against sickness is a preventive of a most serious phase of unemployment.

We have next to observe that the many millions of small weekly contributions from employers and employed build up great insurance funds, and that these funds do not lie idle. In Germany they are wisely used to provide magnificent hospitals and sanatoria, and even for housing purposes. I understand that the German insurance guilds have over £20,000,000 invested in workmen’s dwellings. The same policy will be pursued here.

In view of these exceedingly important considerations, it will be seen that it is not competent for anyone to argue that State insurance against sickness is a mere measure of relief. It is relief and much more than, relief. Exercised in a nation of 45,000,000 people, and applied as it will be to the majority of those that labour, its operation as a real preventive of poverty and as a real preventive of unemployment will be exceedingly far-reaching.

Let us consider the magnitude of the problem tackled by the Act.

We have in 1911 a population of 45,000,000 people, and of these about 20,000,000 men, women, boys and girls, are. engaged in occupations for gain. The number of manual workers or wage-earners is about 15,500,000, and there are some 3,500,000 more persons of small means who are not manual workers, but whose incomes do not exceed the income-tax exemption limit of £160 a year. If we add to these 19,000,000 or so persons their de­pendants, we account for about 39,000,000 persons out of our entire population of 45,000,000. These 39,000,000, it should be remembered, draw only one-half of the entire national income.

So wide is the scope of the Act that it proposes to insure against sickness, with the aid of the State, about 14,000,000 out of the persons between the ages of 16 and 70 who are under the income-tax line of £160 a year, and in addition the few manual workers who have more than £160 a year. Thus the great majority of the working population is brought within the scope of the measure. To this we shall return in more detail.

It is but the minority of the 19,000,000 under the income-tax line who have, through some voluntary social institution, such as a Friendly Society or Trade Union, made any insurance provision against sickness. The number of members subscribing for sick   benefits in 1911 is estimated at about 6,000,000 but, owing to duplications there are probably about 4,500,000 individuals who belong to sickness insurance institutions. Three out of every four of the masses of our working people, that is, are not even nominally insured in this respect. But, as we shall see when we come to examine the subject in detail, a large pro­portion of existing Friendly Society members are not really insured. Two-thirds of the small Friendly Societies are not solvent. It is probable, therefore, that there are not more than about 3,000,000 persons really insured for the benefits for which they are subscribing.

Turning to unemployment,- the case is even worse. Of the 19,000,000 people referred to, the great majority are subject to unemployment in some degree. Of these, about 700,000 are in­sured through their Trade Unions for maintenance in unemploy­ment, and perhaps some 700,000 more have arrangements for working short time and thus pooling whatever work is available without casting any of their number entirely out of work. Thus, not more than 1,400,000 out of 19,000,000 have made provision of any sort against one of the worst of social vicissitudes.

Let us not hastily condemn those who have failed to insure themselves voluntarily. It is the fact that most of our working people have at some time joined a Friendly Society, or Trade Union, or other provident association. If they have failed to remain members, it is because they have been unable to afford to continue to subscribe. Unemployment or other misfortune has come along and swept them out of membership into the ranks of the uninsured. It is in view of. such facts that the principle of compulsory insurance has been adopted in the Act. The Act applies that principle while assisting each insured worker by bringing to his aid a contribution from his employer and a con­tribution from the National Exchequer, and it demands no contribution from him during sickness or unemployment.

The Act also applies the principle of compulsion in respect of unemployment insurance in certain trades, but here we are very largely in the region of experiment, for never before has a Govern­ment legislated in this respect. The principle is tentatively applied to the 2,500,000 workers who are employed in house-building, engineering, and ship-building—the industries which are most severely affected by unemployment. As has been already re­marked, the measure adds to this compulsory insurance the subsidisation of Trade Unions in all trades, to encourage them to undertake voluntary unemployment insurance.

Thus the measure well deserves the title National. It insures the great mass of the workers, and therefore directly or indirectly benefits all but a small fraction of the entire population of the United Kingdom, for to insure the breadwinner against sickness is to insure the bread winner’s dependants against the evils which arise from sickness. In regard to unemployment, it adds to compulsory insurance in the worst cases a scheme capable of universal application to all trades.

(42) The Doctors and national Insurance (See clause 15)

The provisions of the National Insurance Act are of profound, interest to the medical profession. A scheme which, insures against sickness some 14,000,000 persons makes a tremendous demand upon the work of the physician, and those engaged in the noblest and perhaps the most arduous of professions have a right to ask how they will be affected by the Government’s proposals.

The first three sections of Clause 15, which deals with the administration of medical benefit, are briefly as follows:— .

(1) Every Insurance Committee shall for the purpose of administering medical benefit make arrangements with duly qualified medical practitioners in accordance with regulations made by the Insurance Commissioners.

(2) Such regulations shall secure for insured persons “adequate medical attendance and treatment’ and shall require the adoption by every Insurance Committee of the follow­ing provisions:

• The preparation of panels of doctors (the area of a panel will probably be less than that of the Insurance Committee).
• The right of every duly qualified medical man to be included in such panel.
• The right of the insured person to select his doctor from the panel, subject to the doctor’s consent.

(3) The Insurance Committee shall have power to fix an income limit above which the insured person may be required to provide his own doctoring, the Committee paying towards the doctor’s bill such sum as the insured person would cost them if under the income limit.

It will be seen that the plan is to offer all the doctors in a locality the opportunity to enrol themselves on an approved local panel of doctors, and to give the local contributors free choice of doctor from the official panel.

Something has to be done to safeguard the Committee and the State from the possible attempt by some doctors to secure patients, and therefore more emolument, by making a reputation as “soft” doctors, from whom sick certificates can easily be obtained by malingerers. This it is hoped will be done most effectively by applying a check from within the profession itself. The doctors in any district can protect each other and the scheme by forming a committee to watch the interests of the local official doctors as a whole. A special clause sets out that where such a proper “Local Medical Committee’’ is formed, it is to be recognised by the Insurance Commissioners and consulted by the Insurance Committees in connection with the medical side of their duties.

The Insurance Committees will be prohibited (save in special cases) from making any arrangement by which a physician would become his own dispenser.

The local Approved Societies will, of course, have to come to an agreement with the Insurance Committee for the medical treatment of their members and pay them accordingly. Failing agreement, the Act provides for reference to the Insurance Com­missioners, who are to determine the payment-

In this connexion we may note again that the Insurance Committees have, with the consent of the Treasury and Local Authority, power to spend more money on medical work, the cost of such additional expenditure to be shared by the (Government and the Councils. Herein, of course, is a further addition to medical emoluments.

All arrangements made by the Committees with medical men will be subject to the approval of the Insurance Commissioners, and. doctors will thus obtain a protection which club doctors never have now.

As things are, the Sick club doctor is often pushed hard by his clients and finds himself expected, for a low fee per head per annum, not only to prescribe for his patients, but to make up his own medicine and supply the necessary drugs. The fees paid vary considerably, but the average for the whole country appears to be about 4s.per annum, per member including the supply of medicine.

The Government’s scheme provides a sum large enough to increase this payment to 6s. Of this 6s. we may take it that 5s. will go to the doctor and 1s. to the chemist. Thus, where now the doctors get 4s. inclusive of drugs, under the State scheme the doctor gets 5s. apart from drugs.

And while the doctor’s remuneration per member of the Societies is thus raised, it is important for the profession to realise that their work per member is decreased. Under the preventive part of the proposals, the Society doctors will be largely relieved of their chief care—the attendance upon consumptives. About 25 per cent of the sickness of such a Society as the Foresters is due to tuberculosis.

The Government proposes to apply a capital sum of £1,500,000 for the purposes of aiding and stimulating the construction of a chain of sanatoria throughout the country which will have an income, as will be presently seen, of about £1,000,000 per annum.

In this great and beneficent expenditure doctors will, of course, share professionally, since their attendance on sanatoria patients will be essential; but the chief consideration from the doctor’s point of view is that these sanatoria will withdraw from the daily round of their Society work a considerable proportion of their most troublesome patients.

Let us now consider the general relation of the nation’s doctors to this National Insurance scheme.

The Medical Directory for 1911 shows that the number of practitioners in the United Kingdom is about 32,000.

The number of persons to be insured under the Government’s proposals is nearly 14,000,000.

Thus the 32,000 doctors of the United Kingdom, if the insured were distributed equally amongst them, would each become re­sponsible for about 438 persons, apart from patients derived from the middle and upper classes, and apart from the dependents of the insured (it is well as to remember that, as our total population at the beginning of the scheme will he about 45,000,000, 31,000,000 uninsured men, women, and children will remain as private patients after the scheme is launched). But, of course, the number of doctors in practice of a kind which makes them desirous of sharing in the new club income is much less than 32,000.

This may be contrasted with the existing position. As things are, the various Friendly Societies have some 6,000,000 members, corresponding to about 4,500,000 individuals. The average number of existing insured persons per doctor thus works out at less than 50. It is true that doctors find, patients amongst those workers not now insured against sickness, but the average uninsured worker has to be sick indeed before he seeks professional assist­ance, and when he does so the doctor has to take payment when he can get it, which in practice often means never.

Now let us consider the addition which the National scheme makes to the medical and pharmaceutical income of the country. The 4,500,000 Friendly Society members at present pay about £1,000,000 per annum for medical attendance plus medicine. The 14,000,000 to be insured under the National scheme will pay 14,000,000 x 6s., or £4,200,000 per annum, an addition of no less than £3,320,000 per annum to the income of doctors and chemists, chiefly the former. Again, it is true that the £3,320,000 cancels some existing medical income, but the deduction on that head is comparatively insignificant.

In 1903 the British Medical Association made a special inquiry into “Club” doctoring. With what result? It is instructive to find from their published report that the cases inquired into dis­closed an exceedingly low rate of remuneration for club doctors. Here is the record :—

Doctors’ “ Club ” Remuneration.

Per Member per Annum.                          No. of Cases reported on.                      

• Between  2s. and 3s.           …            …            …         135
• ,,               3s. and 4s.           …            …            …         256
• ,,               4s. and 5s.           …            …            …         164,
• Over 5s.                   ..           …            …            …         380

The doctors were asked what scale of remuneration they them­selves recommended. The replies are even more instructive than the above rates. The majority mentioned 4s. or 5s. as their idea of fair remuneration. Some mentioned 6s. or more, but very few were over 6s. Reporting on a certain district of Yorkshire, one medical man said :—

“In this district the orthodox medical men are strongly united, and have demanded and obtain a uniform payment of 5s. per member for all male members.”

These facts are sufficient to show that the treatment of medical men proposed in the Act is by no means ungenerous.

Another important consideration is the national provision for a maternity benefit. The number of working women insured will be about 4,100,000. In addition, the wives of such of the 9,200,000 men as are married will be assured of maternity benefit. We may take it that 1,000,000 births annually will be provided for at 30s. each, which means an expenditure in this respect of £1,500,000, some £500,000 of which will probably be an addition to medical income.

Again, as we have seen, the actuarial calculations provide for largely increased benefits in the time to come, and amongst the additional benefits contemplated are free medical attendance for dependents of the insured, and an extension of the maternity benefit. Thus further additions to assured medical income will accrue as time goes on.

To sum up, the National Insurance scheme endeavours to take the doctor into partnership on equitable terms. If the medical profession were but to regard the proposals from the lowest point of view, that of emolument, it would have cause for considerable satis­faction. But the medical profession has ever shown itself conscious of the peculiar dignity and honour which attach to the. science of healing, and it cannot fail to perceive the grandeur and nobility of the enlarged opportunities for national service’ which the Government scheme creates. The National Insurance Act calls the doctor to his rightful place in the national economy.

(43) The Supply of Medicines. (See Clause 15.)

As is indicated in the last paragraph, the Insurance Com­mittees are not, save in exceptional cases, to make contracts with doctors for medical treatment including the supply of medicines. In the ordinary case, the doctor is only to prescribe, and the insured person is to take the prescription to, a chemist.

The Insurance Committee will prepare a panel of approved chemists, and every duly qualified chemist is to have the right to be included in the panel for his locality for the supply of drugs, &c at an approved scaleof charges.

(44) The Sanatoria and Medical Research Scheme. (See Clauses 8, 16, and 17.)

The National Insurance Act does not content itself with the element of prevention which, is contained, as we have seen, in health insurance. It provides generously for the establishment of institutions which are designed to be sanatoria, and something more than sanatoria.

The first and largest purpose of the sanatoria will naturally be to give institutional treatment to consumptives.

One out of every eleven of the deaths in this country is due to some form of tuberculosis, chiefly the tuberculosis of the lungs which we call consumption. The toll of the “White Scourge” is highest in the working years of life; 56 1/2 per cent, of the deaths take place between the ages of 20 and 45 years, and 25 per cent, of the deaths occur between the ages of 45 and 65. Who shall measure the value of these wasted lives? From the economic point of view, as has been pointed out with so much force by Dr. Arthur Newsholme in his Prevention of Tuberculosis, those who die from tuberculosis are lost to the nation during the very years when they have the chance to repay the debt of their nurture and training. The abolition of consumption would increase the expectation of life of every male aged 15 years by nearly 3 years. Those males who were aged 15 to 25 years at the census of 1901 would, but for consumption, have in the aggregate nearly 8,000,000 more years to live than is at present the case. If we take the average earnings of each at only £1 a week, this would mean a gain of over £400,000,000 from the abolition of consumption in the case of these males alone.

The experience of insurance societies is very striking. 15 per cent of the deaths of members of the Ancient Order of Foresters is due to tuberculosis. It is calculated that in five years the Manchester Unity of Oddfellows experience nearly 1,000,000 weeks of sickness from consumption, entailing an expenditure of about £350,000 for sick and funeral benefits. The German Imperial Insurance experience shows that out of every 1000 German workpeople aged 20 to 45 who are unfit for work as many as 548 are tuberculous.

Taking the United Kingdom as a whole, there are something like 75,000 deaths per annum from tuberculosis at the present time, of which over 50,000 are due to disease of the lungs.

Compare with these terrible figures the small provision which now exists for the special treatment of tubercular patients. In the whole country there are only about 2000 beds available in sanatoria for consumptives. If we assume each patient to be under treatment for four months, that means that only 6000 persons can be given institutional treatment in a year in a country where 75,000 persons die of the disease in a year.

The Government propose to tackle this great problem on a proper scale. They are setting aside the sum of £1,500,000 to assist Local Authorities throughout the United Kingdom to erect sanatoria; the money is to be granted to supplement local effort, and it is earnestly to be hoped that Local Authorities and public- spirited individuals will rise to the occasion.

Then the sanatoria have to be maintained, and that, is a very expensive matter. The proposal is that 1s. per member (not an additional contribution) should be taken from the insurance fund towards the upkeep of these institutions, and that to this the State shall add 4d. That means roundly, for 14,000,000 insured persons alone, a sanatoria income of £1,000,000 a year. And, as we have seen in paragraph 10, the sanatorium benefit may also be extended to the dependants of insured persons.

The Local Authorities will establish (radiating from the sanatoria) tuberculosis dispensaries, under the management of doctors skilled in the diagnosis of the first symptoms of consumption. The ordinary medical practitioner is by no means to be relied upon in this connection, and the importance of early treatment cannot be over-rated.

That sanatoria can in a large proportion of early cases so far arrest consumption as to enable a sufferer to resume his ordinary life if he lives healthily, is well established and the sanatorium benefit undoubtedly means the prolongation of life for tens of thousands. The treatment of advanced cases is also important, not because cure is possible, but because suffering may be alleviated and the infection of the healthy prevented. It is most important to take advanced cases away from their families. it is an awful thing that at this moment a large number of dying consumptives are poisoning those who are dearest to them.

While the treatment of consumption stands out as one of the first objects of this particular fund, it is by no means proposed to limit the activities of these institutions. They will become centres for the treatment of other dread diseases which require in­stitutional treatment, and centres of medical research.

Only the sections relating to health have been reproduced.