AN INTERVIEW WITH ARTHUR C. CHRISTIE, M.D. INTRODUCTION In 1927 on the occasion of the annual meeting of the American Medical Association held in Washington, D.C., a group of lay advocates of compulsory health insurance met during the meeting in order to enlist the cooperation of the medical profession. They approached leaders of the Association with the proposal that a study be made of the economic aspects of medical care. The AMA agreed to participate and a committee was organized to be known as The Committee on the Costs of Medical Care. The Committee consisted of some 50 members representing the fields of private practice, public health, medical institutions and special interests, the social sciences and the general pub­ lic. Dr. Ray Lyman Wilbur was chosen as Chairman of the group and in 1928 it was decided to conduct a 5 year program of re­ search, consisting of 17 studies dealing with the various eco­ nomic aspects of medical care. The Committee was funded by 8 private foundations--the Twentieth Century Fund, the Milbank Memorial Fund, the Russell Sage Foundation, the Carnegie Corpo­ ration, the Rockefeller Foundation, the Julius Rosenwald Fund, the Josiah Macy, Jr. Foundation, and the New York Foundation. The Committee met regularly twice a year. From time to time throughout the 5 year period, selected studies were published. As the final report was being compiled and recommendations pro­ posed, it was obvious that there were significant differences i of opinion between some of the private practitioners and other members of the Committee. Dr. Arthur C. Christie a Committee member representing Private Practice, was asked to write a Minority Report. Dr. Christie, a prominent radiologist in Washington, D.C., was interviewed by Mr. Theodore Wiprud on January 4, 1952. Mr. Wiprud was at that time Executive Director and Secretary of the Medical Society of the District of Columbia. This taped interview is one of three held by Mr. Wiprud with former members of the Committee on the Costs of Medical Care. References: 1) Medical Care for the American People; the final report of the Committee on the Costs of Medical Care adopted Oct. 31, 1932. Chicago. Univ. of Chicago Press. 2) Christie, Arthur C.: Economic problems of Medicine. New York, Macmillan Co. 1935. ii n LYMAN WILBUll, M,o., Ch11Jrmtm C.-E. A. WINSLOW, DI\. P,H., Vice-Cht1hmt1# WINTHROP W• .Al.DI\ICH, Trun1r1t IRE COMMITl'EE ON THE COSTS OF MEDICAL CARE Organized to study the economic aspects of the prevention and care of sickness, including the adequacy, availability, and RESEARCH STAFF EXECUTIVE COMMITTEE compensation of the persons and itgencies concerned --- I. S. FALK, PH.D,, Associafr Directorof St-'y ,•E, A. WINSLOW, Dll. P.H., Ch11Jrmt111 RoBEI\T P. F1scHEus, PHAR,D, WALTER. P. BowElls, M.D. 910 SEVENTEENTH STllEE'I' C. ST.C. GUILD, M,D., DI\. P,H, M1cHAEL M. DAvrs, PH,D. WASHINGTON, D. C. ,,,..-· LEWIS W. )ONES, PH,D, Mu. 'WM. JC.noncun DaAna DoN M. Ga.15w0Lo, M,o., oa. •~11. HAVEN EMEI\SON, M.D. TELEPHONE NATIONAL 5358 ..-· MARGAI\ET c. KLEM ,.,... MAURICE LEVEN, PH,D, GEOI\GE E. FOLLANSBEE, M.D. .,,- Lours S. REED, PH,D. WALTON H. HAMILTON, PH,D. HAnY H. MooRE, P~.o., Director of St•tl1 MARTHA D. RING WALTEil R. STEJNEI., M.D. ALDEN B. MILLS, Executive Secr,t11r1 ,,. C. RuPus RoaEM, PH.D,, c.P.A. ALLON PBEBLB1, PH,D,, Pieltl Secrelt1r:, ,,. Roo211. I. LEE, M.o. GEOI\GE P. MULLER,M.D. MEMBERS ., DAVID RIESMAN, M.D. Con1ult11#tl With Intertsts R.epresent"l l\'ATE PI\ACTICB LEWELLYS F. BARJl'.EI\, M.D. w ALTER P. BOWERS, M.D. - A. c. CHRISTIE, M,D. GEORGE E. FOLLANSBEE, w.p. M. L. HARRIS, M.D. J. SHELTON HORSLEY, M.D. Km.BY S. HowLETT, M.D. ~ ARTHUR C. MORGAN, M,D. HEIi.BER T E. PHILLIPS, D.D.S. • STEWART R. ROBERTS, M,D. c. E. RUDOLPH, D,D.S. RICHAllD M. SMITH, M,D, WALTER R. STEINEll, M.D. -- N. B. VAN ETTEN, M.D. ROBERT WILSON, M.D. RoLLIN T, WooDYATT, w.o. BLIC HEALTH GEORGE H. BIGELOW, M,D. HERMAN N. BUNDESEN, M.D. HAVEN EMERSON, M.D. JOHN SUNDWALL, M,D, EDGAR SYDENSTI\ICKER C.-E. A. WINSLOW, DI\. P,H. STJTUTIONS AND SPECIAL iNTEI\ESTS • ARTHUII. D. BLACK, D.D.s., M,D. w.IRVING CLARJl, M.D. WILLIAM DAR.RACH, M.D. - LOUIS I. DUBLIN, PH.D. ELIZABETH Fox, R,N. AMBROSE HUNSBERGEI\, PHAI..M• . ,ALFRED OWRE, D.M,D,, M,D. w. s.RANJt.JN, M.D. MARY M. ROBERTS, 11..N. . - ► ALPHONSE M. ScHYITALLA, PH.D.­ WtNFORD H. SMITH, M,D, OLIN WEST, M.O.. CJAL SCIENCES MICHAEL M. DAVIS, PH,D. WILLIAM T. FOSTER, PH.D. WALTON H. HAMILTON. PH.~ WESLEY c. MITCHELL, PH.D. TD.LIAM F. OGBUI\N, PH,D. HENRY C. TAnoa, PH.O.. ID! PUBLIC WtNTHJtOP VI. ALDUCH joHN J. CARTY, D.SC. iii MoP.11.lS L. Cooirn,. o.sc. , Ma.s. WM. KINNJCVTT l>aAPB& HoMEI\ FoLJts, LL,o. JOHN P: FREY MRS. WALTEll McNAB MILLEI\ °WR.LIAM J. ScHIIlPPELIN, PH,D. AMELIA SEAI\I RAY LYMAN Wn.11ua, M,D. The following interview took place in the Medical Society building, 1718 M St., N.W., Washington, D.C., on January 4, 1952. Dr. Arthur C. Christie, internationally known radiologist, was asked about his recollections of the Corrnnittee on the Costs of Medical Care of which he had been a member. He is being interviewed by Theodore Wiprud, Executive Director and Secretary of the Medical Society of D.C. Mr. Wiprud has the first question. Mr. W.: The first thing I'd like to ask you Arthur, is when you were ap­ pointed and how your appointment came about. Dr. C.: Well, I was appointed a member of the Corrnnittee on the Costs of Medical Care after the Corrnnittee was quite well established. I'm not absolutely certain whether it was the latter part of 1927 or the first part of 1928 in which I received my appointment. The Corrnnittee was first conceived about 1924 when four or five men met in Washington and established a small corrnnittee which gradually en­ larged itself until the actual formal corrnnittee was formed in 1927 and set up for itself a five-year program. It was financed by several of the foundations, amongst them the 20th Century Fund and --- Mr. W.: Did the government pay any part of it? 2 Dr. C. : No, the government paid no part of it at all. The United States Public Health Service, however, did give certain services that amounted to a great deal, but the actual funds were contributed by the American Medical Association--was one of them--the Commonwealth Fund, the 20th Century Fund, and one other fund that I can't just recall now, but they contributed the money that was necessary for carrying on the Committee's work which required five years and the total sum amounted to about one million dollars. And in addition to that there must have been at least a million dollars worth of contributed services by the U. S. Public Health Service and the AMA and other--American Dental Association, and other associations. Mr. W.: Well then, do you recall how the appointment of--what's the name of the chairman-- Dr. C. : Ray Lyman Wilbur. Mr. W.: Ray Lyman Wilbur came up? Dr. C. : Well, Ray Lyman Wilbur was at that time on leave of absence from the Leland Stanford University, where he was president, and was the 3 Secretary of the Interior in President Hoover's cabinet, and he was a very natural appointee for that particular job of chainnan of the Corrnnittee. Mr. W.: Well, did you know Dr. Wilbur pretty well? Dr. C.: I knew him quite well, yes. Mr. W.: What kind of a man was he, what type of man? Dr. C.: Oh, he was a very affable man, dignified but affable, a very pleasant man to meet and certainly always impressed you as a very able man. Mr. W. : Well, what was the attitude of the doctors on the--that is, doctors of medicine--on the Corrnnittee toward Dr. Wilbur? Dr. C.: Oh, they were all--there was an attitude of great respect and of admiration and of cooperation with him in every possible way. Mr. W. : Well now, later on when the Corrnnittee got functioning, it's a, it's sort of--they were split at least on the results of the study, or at least of the---- 4 Dr. C. : Of the split--didn't come until the very end of the five-year period. There was complete cooperation during the whole time of the study because it was just a matter of studying many different 1?c\-e'w\. things, like group practice under Mr. h~rttm, was studied all over the United States and the practice in industrial plants like the Johnson-Endicott plant in Binghamton, New York, and many other studies of that kind were carried on by different expert persons in those particular fields. During all of that time, the Commit­ tee had, I think, about quarterly meetings, and discussed the problems of what would be studied--there were no questions, there was no question about what the report was going to be until 1932 or the latter part of 1931, when the report was actually gotten together. Mr. W. : Well, the question was raised when it came to the recommendations, what they---- Dr. C. : Yes, the questions were raised when the report of the majority of the Committee was finally read--was made available, then the ques­ tions came into the minds of certain members of the Committee as to the advisability of certain parts of the report--many parts of the report, all members of the Committee were in complete agree­ ment, but there were certain attitudes in the report, certain 5 specific recommendations with which a minority of the Committee did not agree. I might say, with regard to the formation of the Committee which was the first question you asked me, there was an Executive Committee of the Committee on the Costs of Medical Care. The entire Committee was about fifty persons--used to be forty­ eight, but about fifty and an Executive Committee of five was the Committee which carried on the organizational and continuing work of the Corrnnittee during all of the five years, and that Corrnnittee was made up, in part at least, by the chairman, Ray Lyman Wilbur, Dr. C.-E. A. Winslow, who was the professor of Public Health at Yale, Dr. Haven Emerson, who was head of the Health Department of New York City, Dr. Michael Davis, who was the Executive Secretary of the Rosenwald Fund; I think Dr. Follansbee was on the Executive Committee. He was a member of the American Medical Association-­ a practicing surgeon in Cleveland. Mr. W.: Well now, when the recommendations finally were made, there was a Majority--what was called a Majority Report and a Minority Report-­ and then there were other individual reports. Now, as I understand it, the Minority Report was signed by, at least mostly, by doctors who were members of the American Medical Association and were en­ gaged in private practice. In other words, they took the attitude of organized medicine, is that correct? 6 Dr. C. : Yes, that's approximately correct, but---- Mr. W. : Were there any other signers besides doctors on the First Minority Report? Dr. C. : The only other signer besides doctors on the Minority Report was Alphonse Schwitalla, a Catholic priest, who was Dean of the Medical College in St. Louis--a very able man, and he signed the Minority Report without qualifications at all, and with a letter to me per­ sonally, in which he stated his full agreement with the Minority Report. Other members were members of the American Medical Asso­ ciation--all of them--but there were eight of us and we represented different fields of practice. There was Dr. Van Etten, who was an internist of New York City and was later president of the AMA and Dr. Olin West, who was at that time the general manager and secre­ tary of the American Medical Association; Dr. Follansbee of Cleve­ land, who was a surgeon; Dr. Howlett of Tennessee, who was a general practitioner; Dr. Wilson of South Carolina, who was the Dean of the Medical School at the University of South Carolina; I don't just recall now who the other members were, but---- Mr. W.: Let me ask you about some of these men. First of all, I would like L 7 to ask this question. When the Committee got together to submit the prepared recommendations, what was. the situation of Dr. Ray Lyman Wilbur--was he, did he take any sides in this matter of these recommendations? Dr. C. : Oh, he was in full accord with the Majority Report--full accord with the majority of the Committee, and there were other doctors on the Committee on the Costs of Medical Care who were in full accord with the report. Dr. Horsley, for instance of Richmond, a very able surgeon, who was in full accord with the report. Dr. Lewellys Barker, of Johns Hopkins University, was in full accord with the Majority Report, so that there were a considerable number of doctors on the Committee who were in accord with the Majority Report and did not go along. with the Minority Report at all. Mr. W. : Well, I recall that I talked to Dr. Olin West who was one of the signers of the Minority Report and he indicated to me that it was a matter of policy that he signed the Minority Report and he really wasn't much in favor of it. Do you recall that in that report was at least the basic principles of the so-called Milwaukee Plan? Dr. C. : Yes, I recall that. 8 Mr. W. : And do you recall that was sort of, that was one of the early pro­ posed prepayment plans? Dr. C. : Well, at that time, Olin West was entirely opposed to even group hospitalization--to any type of insurance plan--he was completely opposed to. And I think it ought to be pointed out now, for the sake of the record, that the Minority Report of the Committee was in some ways a compromise just as the Majority Report was, because it had to correlate and compose the opinions of many different men, and in some respects it didn't exactly state the opinions of any one of us. We could have modified it--any one of us would have modified it a good deal--but in order to have an opinion upon which at least eight or ten of us could agree, there had to be some con­ siderable compromise, and in that, some of Dr. West's opinions were-­ (Mr. W.: incorporated)--incorporated, although some of us didn't agree with them. Now I would just like to state with regard to the way the report came about--when the final report was made, it was written pretty largely by Isidor Falk. Isidor Falk was the assis­ tant to Harry Moore, who was the Executive Director of the Commit­ tee on the Costs of Medical Care, and Mr. Moore was largely an exec­ utive who carried on the general work of the Committee, but the policies of the Committee were pretty largely established, and I 9 believe carried out, by Isidor Falk, and I believe he had a very determining influence in what the report was like; he had a great influence I think upon Dr. Wilbur, upon Dr. Winslow, who was one of the main men in the guidance of the report, and I'm quite sure that the phraseology of the entire report was that of Dr. Falk, who has ever since then been a member of--in the social security department of the government. [Interruption in interview to have tape rerun to listen to inter­ view up to this point.] Mr. W.: Well now, in resuming our discussion, I would like to ask you some questions about people with whom you worked on the Committee. You've spoken about Dr. Falk, I suppose--did you call him Dr. Falk? Dr. C. : Yes, yes, he's a doctor of philosophy--a very able man. Mr. W.: Did you have the impression that he was perfectly sincere in his proposals and---- Dr. C. : Oh, I think there was no doubt about it. He was an absolutely honest man, thoroughly convinced that he's right in his attitude towards the practice of medicine, and completely sincere in everything, I'm sure. 10 Mr. W. : Was he antagonistic towards the American Medical Association? Dr. C. : I think--he never showed that he was antagonistic, he always went along in an affable sort of way, but his basic philosophy and his convictions were quite opposed to the convictions and philosophy of the American Medical Association at that time. Mr. W.: Do you recall what the attitude of the minority group was toward group practice? I don't have the report here, but there was quite a bit of discussion apparently. Dr. C.: Yes, I recall very well what the attitude was then of the minority with regard to group practice. It was not uncompromisingly, the attitude of the American Medical Association. We approved group practice where group practice seemed to be a natural development in any particular situation. As a single method of medical practice, we opposed it. We felt that it was, in some sense, an artificial method of practice, was not the natural method of practice, and that it did have a good deal to do with doing away with the per­ sonal relationship between a physician and his patients. We emphasized that, but we emphasized the idea particularly, that the Majority Report had placed that as one of the crucial and most 11 important recommendations that it had made. That practice should be carried out altogether according to the Majority Report--through groups of medical practitioners--not through single practitioners at all; that was--they emphasized that and set it down in their report as the first and most important recommendation that they had to make, and we said in our Minority Report that we felt that that was out of focus; that it was overemphasized and that it was not so important that the majority had made it seem to be and that it would completely change the method of medical practice in the United States so that there would be an overall control by cer­ tain large groups of men instead of its having a general dissemina­ tion through the medical profession. That was our attitude at that time towards group practice, and I believe our attitude at the present time would be very much the same; I think that is the gen­ eral attitude of physicians at the present time; that group prac­ tice, wherever it is a natural development, has been of great value and has been a way of progress or in certain aspects of med­ ical practice, but that to make it the one method of medical practice was wrong then and we think still is wrong. Mr. W.: Well, let me ask you this. Was there any discussion at that time-­ and again I haven't the report here to verify the information I'm seeking--and that is was it the proposal of the majority in the Majority Report that these group clinics, so-called, be conducted ~, --------------------- I 12 in a manner of, or on a prepayment basis so far as subscribers are concerned? Dr. C. : Oh yes, that was to be done. It was very.much more far reaching recommendation than just for group practice. It was for the es­ tablishment of large medical centers in every community so that all medical practice would be carried out in one or two or three or four large medical centers in the community and that all of the medical practice would be directed from those medical centers, and that all of them would be financed through a compulsory type of health insurance. That was the definite and specific recom­ mendation of the majority of the Committee. Mr. W. : What was the attitude of your group--that is the group that pre­ pared the Minority Report--toward private group practice? Dr. C. : Well, we said at the end of our report that we recommended that group practice be fostered wherever became--it came as a natural development in any particular situation. We didn't oppose it; we didn't look upon it as a panacea at all and we thought that it had hardly anything to do with the main question that the Committee on the Costs of Medical Care had been established to determine, and that was the cost of medical care that it would have no effect at 13 all in lessening the cost of medical care. Mr. W. : Is it your recollection that the American Medical Association at that time, say in the early '30's, was opposed to private group practice? Dr. C.: Yes, the general management of the American Medical Association was opposed to, made itself known in editorials and otherwise and by its spokesmen, Olin West and Dr. Fishbein and Dr. Leland, who was at the head of the committee--the Economic Committee of the American Medical Association--it made itself known as op­ posed to group practice generally-- Mr. W.: In any form? Dr. C.: --in any form. Mr. W. : The statement is made in a report prepared by Dr. Leland in 1940 and this statement has to do with group practice, the AMA never approved, never opposed rather, private group practice and as proof of that fact they point to the election of Drs. Mayo and 14 others in the Mayo Clinic to the presidency of the AMA. On the other hand, Dr. Leland--and you remember I read you a statement a few minutes ago in the California and Western Medicine--he says definitely, that the AMA came out against any form of group practice. Dr. C.: I think Dr. Leland was rationalizing his position in 1940 when he made such a statement because there was quite a difference in concept between such an organization as the Mayo Clinic, or the Lahey Clinic or any great clinic of that type to our conception of what we mean by group practice. The general idea of group practice I think, was undoubtedly opposed by the board of trust­ ees and the general management of the American Medical Associa­ tion at that time, but it was not generally held through the medical profession; we were not generally opposed to it, in fact, we went along complacently with the idea of groups being formed and had no particular opposition to it at all. Mr. W.: Well, now I think at this point that we might go back for just a --to the beginning of our discussion for just a minute-- You said in the beginning that in 1924 four or five physicians got to­ gether to discuss this survey or the organization of the Committee on the Costs of Medical Care. 15 Dr. C. : No, I didn't say physicians because that is not true. Mr. W.: Do you know who the four were? Dr. C. : I think the men who originally established the Committee on the Costs of Medical Care were Dr. Ray Lyman Wilbur, Dr. C. -E. A. Winslow, and probably Dr. Michael Davis, and perhaps Dr. Haven Emerson of New York. Those were the four men that I had in mind as the original movers in the establishment of the Committee on the Costs of Medical Care. Mr. W. : Would you care to give any impression of these four men. You know Michael Davis is here in the city and we still see him once in awhile and---- Dr. C. : Yes, Michael Davis, like Isidor Falk--and they were great personal friends and entirely in accord with their, with each others phi­ losophy of the practice of medicine--both of them were what you might call professional social workers in the social field. Michael Davis at the head of the Rosenwald Fund and had been for years and continues I think to be at the present time, I'm not 16 sure about that, but he was at the time of the Committee on the Costs of Medical Care head of the Rosenwald Fund and he was in entire accord with the final report of the Committee on the Costs of Medical Care in that he advocated great community cen­ ters through which medical practice should be carried out and the financing of medical practice by compulsory health insur­ ance. He's been consistent in that from the very start and he always opposed the American Medical Associations' ideas in re­ gard to compulsory health insurance and there was always a good deal of really animosity between Michael Davis and the general managers in the American Medical Association. Mr. W.: Yes, I know that. Dr. C.: Yes, there was no doubt about that at all, but he was an able man and I'm sure like Isidor Falk a perfectly honest man--thoroughly honest and sincere in his convictions. Mr. W.: Well, I felt that to be true too. Well, now it seems to me that we come back to the place where we left off a moment ago. We were talking about the work of this committee--that is the group that split off, the minority group. Do you recall any of the incidents during your meetings when you discussed issues where 17 differences of opinions arose and where the matter was settled with difficulty? Do you recall any of that? Dr. C.: It didn't take place, as I said awhile ago, in the meetings dur­ ing the general consideration during this five year period. It came about right at the end. The Committee finally determined at the end of five years that it had gone as far as it could in its deliberations and investigations with the amount of money that would be available, although there was some idea amongst some of them that they ought to carry on farther. They deter­ mined that they had to set a certain date in 1932 when this re­ port would have been finished and would be brought before the Committee. And on a certain date--I've forgotten the date now --but on a certain date, that Committee, that report which was prepared under the direction of the Executive Committee--I'm quite sure by Dr. Falk--was presented to each one of us on the Committee, and we--a plenary session of the Committee was called in order to vote upon it, and there was a great deal of pressure at that moment for a vote of the entire Committee but there were several on the Committee, amongst them Olin West and Dr. Follans­ bee and Dr. Van Etten-- Dr. Wilson of South Carolina, who opposed voting upon the report at that time unless we would be given an opportunity to prepare a Minority Report. So, they said, "Well, 18 we've got to get this out within three days, and if you can pre­ pare a Minority Report within three days we will publish a Minor­ ity Report along with the Majority Report," and we said that that seems like a very short time in which to present our views, but we'll attempt to do it. And so, after the meeting on that day, Dr. Olin West, Dr. Follansbee came to me and asked me if I would be the secretary of the minority and would write up the Minority Report with certain notes that they would give me to incorporate in it. I thought it was a tremendous job and it turned out to be a tremendous job, so that I spent at least two sleepless nights writing all night in order to finally write this report and the report as it is--the Minority Report--as it is written was written entirely by me, and is an attempt to compromise somewhat the views of the different members of the minority, and at the same time to present my own convictions. Mr. W.: Did you meet with the minority group before you wrote the report? Dr. C. : No, we didn't meet with the minority group, which scattered to the different cities in which we lived then, and I sent that re­ port in by air mail to each one of the--sent it to all the mem­ bers of the Committee--and, not knowing who would be in agreement with it at all, and except that there were three or four whom I ·-· • - - - - 19 knew would generally agree with this Minority Report, and in the end, it turned out that nine persons on the Committee on the Costs of Medical Care were in accord with this main Minority Re­ port and signed it in the end. Mr. W. : Well now, of course, this study--the study on the Committee on the Costs of Medical Care was the first extensive study ever made of medical care in this country, wouldn't you say? Dr. C. : Yes, it was referred most extensive ever made without a doubt. Mr. W. : And it's referred to now as a beginning of the period in which there was a great interest in planning medical services, is that right? Dr. C.: Without a doubt. Mr. W. : Now, as you look back at it, do you think that there was any mis­ takes made by your group in its recommendations--that is the minor­ ity group? Dr. C.: Yes, yes, I think there was a mistake in emphasis in one thing, 20 and that I'd like to point out. We stated in our report that we were opposed, not only to compulsory health insurance, but to voluntary health insurance also. We stated that in the Minority Report. Now, it should be understood that what we were thinking about at that time--as voluntary insurance-- was the kind of voluntary insurance that had been prevalent up to that time; that we had never had, for instance, group hospi­ talization or any voluntary types of insurance that were limited to certain types of care as we have today, but we were thinking of the old types of contract practice and insurance by lodges, and all that sort of thing to which we were opposed and to which, I think, all right thinking men are opposed even at the present time, and I'm sure that every one of the minority, perhaps with one exception, would be in favor today and certainly we've been amongst the ones who have worked the hardest to put voluntary insurance into operation during these intervening years, so that we would not certainly be opposed to the type of limited volun­ tary insurance that has been built up during these years. Our opposition was to that shotgun-type of insurance that tried to cover all types of medical care and that we were certain would lead to all the evils that the old methods of contract practice and large practice had fostered in the past. Mr. W.: But, as you state in your report that voluntary health insurance 21 inevitably leads to compulsory health insurance. Dr. C.: We did so. We believed that and we thought that it would, but we had in mind that type of voluntary insurance which was not limited to some particular part of medical care and which could be sound in its financial aspects. The reason we believed that voluntary insurance would lead to compulsory insurance was that we felt that no type of voluntary insurance had ever been de­ vised up to that time could be sound financially, and since it wouldn't be sound financially then it would inevitably lead to compulsory health insurance. Mr. W.: Well then, you didn't visualize at that time voluntary health insurance plans sponsored by medical societies, although you did refer to our, to the prepayment plan that we proposed in Milwaukee. Dr. C. : We did and we didn't understand that voluntary insurance could cover just limited fields and in that way could be financially sound--as we see now, and as we saw soon after the time of that report. Mr. W. : Well, that was the one mistake.probably you made in that report. 22 Dr. C.: We think so, and we believe that that's the only fundamental mis­ take that we made in it; that the rest of the report could stand today, so far as I can see as sound as it was in the day when it was written twenty years ago. Mr. W. : I wish you would clarify though the--your recommendation as re­ gards group practice. You say that you are not opposed to group practice if it was a natural development. Well, I just don't know what you mean by that---- Dr. C.: We mean this, we meant exactly this and we mean the same thing today, that if groups are set up by governmental action--com­ munity centers are formed for instance by community and govern­ mental action which is an artificial way of doing it--it means statism and the control of practice by the state. If groups are voluntarily formed among doctors we have no objection to that at all. Mr. W. : Well, that's the point I wanted to get at. Dr. C. : That's exactly our attitude then; it would be our attitude now. - 23 Mr. W.: Of course, the AMA was even opposed to the type of thing we planned in Milwaukee--the so-called Milwaukee Plan. Dr. C. : Of course they were--no doubt about that, but the majority of our committee would not--of our minority group--was not opposed to group practice generally at all. Olin West, who was on that minority was opposed to it, but I think all of the rest of us were in favor of going along with group practice wherever it would be a natural development. Mr. W. : Well now, I'm wondering if there's any other phase of the re­ port--that is the preparation of the report--that you'd like to speak about because after all this will be for posterity, Arthur. Have you got anything to say about it? Dr. C.: Well, we had a great debate afterwards with regards to the sound­ ness of the majority and the minority position. The great divi­ sion took place just on two aspects of the Majority Report. One was the--what we considered to be the overemphasis upon community centers as the one way _of practicing medicine and their financing by compulsory health insurance. And upon those two points we were opposed and I think remain opposed to this very day. We don't 24 believe that they are sound and we think that they will lead to statism and to complete control of medicine by the state in the end. Either one of them or both--and they both have to work to­ gether in order for either one of them to be successful--they have to have both methods working at the same time. Now we had debates all over the country. I myself debated with Dr. Horsley before the Academy of Medicine in Richmond; with Ray Lyman Wil­ bur before the California State Medical Association; with Dr. Llewellys Barker in a great public meeting in the Lyric Theater in Baltimore, and at other meetings all over the country I was invited to speak. Mr. W.: Well, was this after the report came out? Dr. C. : That was after the report came out during the intervening two or three years. Mr. W. : Well, my impression or my feeling has always been that the state medical societies and the county societies have been much more progressive than the American Medical Association. What is your feeling in regards to that as it relates to this----- Dr. C. : There's no question in mind about that at all. The fact that 25 state societies all over the country wanted to hear about the two sides of it and gave us an opportunity to present the two sides before, for instance, the California State Medical Asso­ ciation where it took the chairman of the Committee himself to present it--showed that state societies were anxious to arrive at the correct stand with regard to it, hut in the end, state societies and county societies couldn't generally over the country approve in principle the attitude of the Minority Report. Mr. W.: Well now, this is a little aside from what we've been talking about, but if I recall correctly, you wrote a book about 1934 or 1935 on medical economic problems-- Dr. C.: Yes, I did. Mr. W.: --or economics of medicine or something of the sort-- Dr. C. : Yes, you can call it that, I guess. Mr. W.: --and at that time you were very active here in Washington in the development of the Medical Dental Bureau and the--! may be wrong on this, but you can correct me--and the Central Admitting Bureau 26 for Hospitals-- Dr. C. : That's true. Mr. W.: --and did you have a feeling then that the postpayment plans had any real value in medicine? Dr. C.: Oh yes, I was certain that they did--you mean prepayment plans. Mr. W.: Postpayment. Don't you recall that after all the Medical Dental Bureau was a postpayment plan? Dr. C.: Oh yes, of course. Well, I did feel that postpayment plans were of value too, but of limited value, but of real value after all, but it was at that time that we began the organization of our group hospitalization which was a prepayment plan--1934 that was organized--and I was one of the members of the board of directors at that time and have been a member ever since, appointed by the medical society. Mr. W. : Was there any opposition to the development of group hospitaliza­ tion on the part of the medical society here at that time? 27 Dr. C. : Not strong opposition, there was some opposition. Mr. W.: What about the AMA--did they come---- Dr. C. : The AMA was opposed to it. Dr. Olin West himself made a visit to my office and spent at least two hours sitting and talking to me and he said that it's just the opening wedge to compulsory health insurance and we're opposed to it just the same as we are to any method of any insurance. He told me that in my office. Mr. W.: Well, that sounds familiar because he told me the same thing about the Milwaukee Plan. Dr. C.: Well, he was opposed to it and the American Medical Association was opposed to it at that time. We worked hard for it here in Washington. Mr. Hines who has been chairman of our board of directors of group hospitalization ever since its organization and it's due to him largely that it's been such a great success --came before our medical society over and over again to persuade the society of the rightness of this action and the society fi­ nally went along with a very good majority in approving group hospitalization. 11111 28 Mr. W.: Well now, Arthur, is there anything else that you would like to say about this report? Dr. C.: Well, I can think of nothing, except to say in a very general way that I believe the work of the Committee on the Costs of Medical Care was greatly justified; that it was a pioneer work that marked the beginning of a new era in medicine and that it did a great deal of good; that the Minority Report helped to correct somewhat the overemphasis of the Majority Report; that the two together came to be a mark of advance and of a great body of facts and opinions which could be looked back to--taken as a starting point --for a completely new era in medicine, and altogether I believe that it has been an excellent thing. I'm reminded of the old saying that there are always two sides to a question, but the fact of the matter is that there are usually three sides to it-­ that there's your side and my side and the right side and I think we finally arrived at what is the right side by a compromise of the views that were expressed on the two opposing sides of this Committee. Those men who were in favor of the Majority Report were very sincere men, and I believe now that they were short­ sighted in their attitudes--for instance, Dr. Ray Lyman Wilbur, Dr. Lewellys Barker, and Dr. Horsley, all of whom were very able and very sincere men. Dr. Horsley was a very close personal 29 friend of mine and it was through him I'm sure that I was ap­ pointed to the Committee on the Costs of Medical Care, but in the end, we found ourselves opposed and debating to opposed views before the Richmond Medical Society. Those men were all very sincere and I believe to this day that those able men missed a very great opportunity of making what could have been a much greater advance in medical care if they had been willing to take advice from doctors in general practice and the general run of medical men rather than to have gone off on this "doctrinaire" stand of a great medical center in each community, which I be­ lieve can be recognized today as an absolutely impractical and utterly undesirable method of practicing medicine. Mr. W. : Who do you consider the outstanding members of that Committee? As you look back you mentioned some of them and I don't think it's necessary to repeat that--such as Falk and Michael Davis and Horsley and those men--can you think of any other men that would stand out on the Committee who you think rendered real service? Dr. C. : The only other ones that I think of were Follansbee, for in­ stance, of Cleveland, who was a very able man. 30 Mr. W.: Well, he was a very fine man. Dr. C. : Yes, he was, he was a very fine man and a very able man and he-­ one of the parts of the Minority Report that deals with the per­ sonal relationship of physician and patient where--is down in that Minority Report in his words, and they really are quite eloquent words in regard to the position of the general practi­ tioner and his relationship to his--the patient. Follansbee was an influential and able and very hard working member of the Com­ mittee on the Costs of Medical Care. Mr. W.: As I remember him too he was a very distinguished looking man with a goatee. Dr. C. : Yes, he was, he was a distinguished looking man and was distin­ guished in his practice and in his whole attitude towards the practice of medicine and gave very great service on the Committee on the Costs of Medical Care. Mr. W.: Ah, you know these reminiscences or recollections are flavored by the instances that you might recall and if you do, well, we 31 might incorporate them here. You might think a moment while I pose this to you. We're living in 1952 and thirty years have passed--a, twenty years have passed since the Committee on the Costs of Medical Care reports were made and a lot of things have happened in those twenty years. What is your view of the medi­ cal scene at the present time--you know there's quite a furor about legislation, compulsory health insurance and this new com­ mission on medical needs appointed by the president. What do you think about the current medical scene? Dr. C. : Well, I've been very much encouraged over the whole situation. I think the leadership of Dr. Henderson was very salutary and progressive and constructive. Mr. W.: You're speaking of Dr. Henderson, president of the AMA? Dr. C. : YeB. He led us in a way that 1--and I wrote him to that effect when he was leaving the presidency--of my admiration for him and my feeling that he had led us to a point where we were on very much sounder ground than we had ever been before. I believe, however, that the---- Mr. W.: Just a moment, right here. Do you, did you favor the educational 32 program in the AMA, educational campaign? Dr. C. : Yes, I favored it because I thought it was a necessary thing. I thought that there was no other way that, but to go to those great extremes. Unfortunately, they seemed to be necessary in order to offset the headway that compulsory health insurance had made among the people of the country. I deprecated a good deal at doing, having to do things in that way, but it seemed to me that that was a necessary thing to do and that we had to take some drastic means if we were going to stem the tide at all. I believe it was right that we did it and I still feel that way. I do feel that the report of the minority of the Committee on the Costs of Medical Care has been vindicated in this respect; that we were particularly opposed to compulsory health insurance; we would still be opposed to it; it's the one method that will lead to statism; it's the shortest method in-­ to the complete socialization of medicine that anybody could possibly devise, and it would make, in this country, the great­ est bureaucratic regime that the country has ever known or that any country has ever known, because it would be so much larger than it had ever been in any other country. So I think that we're justified in that situation. I believe that the American Medical Association organizing medicine in general learned a great deal from the hard knocks that it received during all of 33 those years and I'm greatly in hopes that we can learn to com­ promise our differences and can show the people of the United States that we're really going forward to help in the construc­ tive building of medicine instead of being all constantly in opposition. Mr. W. : Now, you've given us some advice here to organized medicine. Might we close with some advice to the medical profession, if you have any to give--that is a doctor generally. Dr. C.: Well, my advice, I think, will be based upon my whole philosophy of medicine as a matter of service to the people, the tension of the personal relationships with the patient--we should be the friends of our patients--that medical practice is a great ideal­ istic system that must never be corrnnercialized and that money should never be emphasized as the guiding influence in any posi­ tion of life. Mr. W. : Well, I think that's a very fine statement. Well now, Arthur, unless there's something more, I think we can bring this to a close. Dr. C.: I think of nothing more that I would like to say at the present 34 time. It's been all very, in a very informal sort of way, of course, and I would say more if I had a chance to write it down, I suppose, but I think I've given the principle points that actuated us on the minority of the Committee on the Costs of Medical Care and have shown how we would--how we would, how time has changed our views somewhat, as I hope it has changed the views of some of the leading men on the--who signed the Majority Report, although those men who were convinced of-­ that our country must be socialized are still so convinced and I suppose will work for that socialization, and if that ever takes place medicine will have to go along with it. Mr. W.: Well, just one more question on that point--do you think that we have lost ground, and by we I mean organized medicine, in the twenty years that have passed? Dr. C. : Oh no, we've greatly gained ground, I think. We've gained ground tremendously in almost every aspect even where we--the ideas, some of our ideas were defeated--they were found to be wrong ideas and in that we've gained ground because we're on sounder ground than we were before. Mr. W. : Well, now let me put it the other way. Do you think that proponents "'" ~ $[."' '<l\1fu.~ ~ I ~.,,~,..,.,.,._,.,J,;, - 35 of health insurance--and I'm not stating whether it's compulsory or voluntary, but just health insurance--have made any advances? Of course they have, but well, lets limit it to compulsory health insurance. Do you think the proponents of compulsory health in­ surance have made any progress? Dr. C.: They did make progress, but it has been pretty well stopped now, I think. I believe that if we can maintain the confidence of the American people as a profession that we will have perman­ ently stopped compulsory health insurance, but if we lose their confidence again by a bad press or something of that kind, we can very easily have compulsory health insurance. That's one reason-­ I might just say it here--that I deprecate very greatly any divi- sion at the present time on nonessential points. For instance, I don't believe that it's necessary at all to oppose this new commission that the president has set up for the study of the health of the nation. I don't believe we're going to get any­ where by doing such a thing as that. I think that we hurt our­ selves--it's already shown in the press that the people will not go along with any such attitude. Why should we oppose ourselves to the study of health in the United States especially led by a man like Paul Magnuson, who is an honest and sincere man and who's views are not extreme in any way at all, and who's views, I be­ lieve, will dominate this commission of which he's the head, and 36 in the end will probably be a gain for medicine? Why should we oppose a commission of that kind? Mr. W. : Well, I thoroughly agree with you on that and I have so written Dr. Magnuson. Dr. C. : Well, I'm glad to hear you say that, because Paul Magnuson is an able man. We've had our differences in the Veteran's Bureau-- I'm on the advisory committee of the Veteran's Bureau--and we had our differences there with Dr. Magnuson, but in a general way we were all in favor of all of his great reforms in the Bureau, and went along with him in every way. He's just so intense in his likes and dislikes and his convictions, that he is a rather diffi­ cult man to work with but, in this sort of general investigation of which he's the head now, he will do a great job, I believe. Mr. W. : Well, Arthur, thank you very much and if you have anything to add to this, well, we'll be glad to receive it. I might tell you that we will--it will take a little time to type this conversation--it's quite lengthy--but as soon as we've made a draft of it or have a draft typed, we will turn it over to you. ~ { '"'""'~•,d',f, 1i,,[~,i:,.;,. ..s A ~ . . " I 37 Dr. C.: All right. Of course, there'll have to be many deletions in it. Mr. W.: O.K. 38 INDEX American Dental Association 2 American Medical Association 2, 5, 6, 10, 13, 14, 16, 23, 24, 27, 32 Barker, Lewellys F. 7, 24, 28 Commonwealth Fund 2 Davis, Michael M. 5, 15, 16, 29 Emerson, Haven 5, 15 Falk, Isidor S. 8-10, 16, 17, 29 Fishbein, Morris 13 Follansbee, George E. 5, 17, 18, 29 Henderson, Elmer L. 31 Hoover, Herbert 3 Horsley, J. Shelton 7, 24, 28, 29 Howlett, Kirby S. 6 Lahey Clinic 14 Leland, Roscoe G. 13, 14 Magnuson, Paul 35 Mayo Clinic 14 Milwaukee Plan 7, 21, 23, 27 Minority Report (of Committee on the Costs of Medical Care) 5, 11, 12, 17-20, 25, 28, 30, 32, 34 Moore, Harry H. 8 Rorem, C. Rufus 4 Schwittalla, Alphonse M. 5 20th Century Fund 2 39 U. S. Public Health Service 2 Van Etten, N. B. 6, 17 Veteran's Bureau 36 West, Olin 6, 7, 8, 13, 17, 18, 23, 27 Wilbur, Ray Lyman 2, 5, 7, 9, 15, 24, 28 Wilson, Robert 6, 17 Winslow, C.- Eo A. 5, 9, 15