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One portion of Mr. O'Connor's 17-fooMong bflfc

for the past three, the MGH has had to raise its charges. Nor is the teaching hospital unique in its financial squeeze. All American hospitals are raising their charges at this same rate.

Second, hospitalization cost has increased much more rapidly than other goods and services in the economy. Medical care is the fastest-rising item in the consumer price index in recent years, and per day hospital cost accounts for the largest proportion of this increase. [Physicians' fees have also been rising faster than other items in the consumer price index. However, hospital costs have been nearly doubled in the past decade, while physicians' fees have increased 30 per cent].

Third, the individual contemplating hospitaliza-tion no longer worries much, in a direct way, about cost. Third-party payment has led to public apathy about hospital costs, and this is unwise-if for no other reason than the fact that most people have only one fourth to one third of their costs paid by insurance, a fact they discover late in the game.

Fourth, the often overlapping coverage of health insurance permits some patients to make money from their hospitalization, while welfare reimbursements are always less than the true costs of care. In this situation, the hospital makes ends meet by overcharging private patients and their insurance companies to cover the welfare deficit-in the case of the MGH, roughly $10 a day overcharge.

Fifth, no single hospital stands alone in its financing problems, but rather is influenced by the activity or decline of other hospitals in the area. The decay of the Boston City Hospital, and its reduction in size to nearly half its earlier patient capacity, has created great pressure upon other Boston hospitals to take up the slack-by accepting precisely those patients on whom the hospital loses money, namely, patients covered by welfare.

The decline of Boston's municipal, tax-supported hospital is similar to the decline of other such institutions in other American cities. In each case, the reasons behind the decline are political and financial, but the consequences are always the same-to pass on costs to insured patients, and make them augment insufficient tax funding for welfare. In the long run, of course, it all works out to the same thing: one can either pay the money in taxes or in higher health-insurance premiums. But in such a situation, it is probably more efficient to choose one or the other-and the trend unmistakably is toward universal health insurance in this country. Dr. John Knowles notes that many Americans are required by law to arrange insurance for their cars; why should they not also be required to arrange health insurance for themselves?

Sixth, lest private health insurance seem a financial panacea, one should note that private companies are often irrational in their payment procedures. For example, for many years one could not collect for certain treatments-such as the setting of fractures-unless one were admitted to the hospital, at least overnight. Thus a person who might easily receive therapy in the EW and be sent home had to be admitted in order to receive insurance coverage. This unnecessary admission raised the total cost of health care, and ultimately such increases are passed on to the consumer in the form of higher premiums. Some of these odd payment procedures have been changed, but not all.

Seventh, the American medical system in its full spectrum-from the private specialist's office to the municipal hospital wards-has never been able to structure the kind of competitive situation that encourages and rewards economies. Nor has American medicine tried. The American physician has been grossly irresponsible in nearly all matters relating to the cost of medical care. One can trace this irresponsibility quite directly to the American Medical Association.

For the past forty years, the American Medical Association has worked to the detriment of the patient in nearly every way imaginable; it is a peculiarity of this organization that it has worked to the detriment of physicians, as well. Dr. James Howard Means has said: "Its ideology is very like that of the big labor unions… it has now set up a continuing political action committee quite like those of the fighting labor unions. Every attempt that has been made by liberally minded groups to improve medical care and make it more accessible… the AMA has attacked with ever increasing trucu-lence… They forget perhaps that medicine is for the people, not for the doctors. They need some enlightenment on this point."

The truculence of the AMA has been expensive. In terms of the modern-day cost of medical care, we may cite the following points. Beginning in 1930, it opposed voluntary health insurance, such as Blue Cross. In 1932, it opposed prepaid group-practice clinics. In 1933, it began a successful campaign to block the construction of new medical schools and limit enrollment in those already in existence. We now have a shortage of doctors. More recently, the AMA spent millions-probably no one knows exactly how many millions-to fight Medicare, a program that resulted in health benefits to 10 per cent of the population and vastly increased income to physicians. (Indeed, a good gauge of the AMA's shortsightedness can be gained by imagining the outcry from private doctors should anyone now try to repeal Medicare.) Further, the AMA has failed to take any strong stand on prescription pharmaceutical prices in this country, which nearly every objective observer regards as grossly inflated. And more insidiously, the AMA has permitted what may politely be called blind spots in health care. The Journal of the American Medical Association refused to print a government study of combination-antibiotic drugs which concluded that many of these expensive medications are either worthless or dangerous; the AMA has still failed to condemn cigarette smoking despite overwhelming evidence that this habit, though profitable to certain industrial groups, is directly responsible for much disease, suffering, and medical expenses in this country.

One can only conclude that the American Medical Association has not considered the interests of patients for forty years, or perhaps longer. On the basis of its record, it is opposed to both better and cheaper medical care. Its only commitment is to the doctor's bank account-and even then, it makes astonishing errors in judgment.

In 1967, in his inaugural address, Milford O. Rouse, the incoming president of the AMA, deplored the growing sentiment in this country that medical care was a right, not a privilege. His opinion was not well received by an angry public, and later presidents have been more circumspect in voicing their views. Nonetheless, it is customary for AMA presidents to travel about, speaking to groups of doctors, applauding what they call "the phenomenal growth of the health industry."

That growth cannot be questioned. Personal consumption expenditures for medical care rose from $7.5 billion in 1948 to over $27 billion in 1965, and more than $50 billion in 1968. By 1975, it is expected to reach $100 billion or more. This is the sort of news to make a Wall Street broker squeal with delight. But medicine is a service, not an industry, and one really ought to look at it differently.

In fact, the United States spends more of its gross national product (6.2 per cent) on medical care than any other country in the world; it spends a larger absolute sum than any other country in the world. Yet by most objective standards of health- infant mortality, life expectancy, and so on-it is far from the leader.

Other countries are doing better, and most of them have some form of socialized medicine. The United States is extraordinarily backwards in this respect. However, many clear-headed American observers have looked at European socialized systems and have come away shaking their heads; and there is a widespread doubt whether any European system can be adapted to this country. Very likely, America will have to work out its own system. The combination of group insurance with a group-practice system (essentially the system at Kaiser and others) seems a feasible, economical, and practical method, acceptable both to doctors and patients.

Without question, the notion of the doctor as a legitimate fee-for-service entrepreneur, making his fortune from the misfortunes of his patients, is old-fashioned, distasteful, and doomed. It is only a question of time.