A bitter public debate is in progress in the United States over the question of medical care for the poor. Broadly speaking, American Liberals are insisting that the health of the poor is an obligation of the Government. The American Medical Association, the powerful national society of physicians and surgeons, resists this tendency as leading towards “Socialism” and endangering the relation between doctor and patient.

In this country there is, of course, no equivalent for the “panel doctor” or for the plans for socialised medicine existing in most European countries. In theory at least every physician is in private practice. His well-to-do patients pay him fees large enough to cover that proportion of his time that he devotes to free service among the poor. The chief complaint made about this scheme is that in fact the poor man is never certain that he will get good service, or in some instances any at all. Moreover, numerous persons in the lower middle class have incomes sufficiently large to prevent their taking advantage of free service, yet they find the financial burden of a serious illness a disaster from which it takes years to recover.

Public clinic

Within the past few years various schemes have sprung up which are on a border-line between public and private medical practice. There are public clinics which on payment of a fixed fee, usually £5 or £6 per annum, undertake to and give unlimited medical, dental and nursing-home service. These organisations retain their physicians, dentists, and other staff members on a fixed annual salary. They may have no outside practice, and are supposed to care for as many patients per day as they reasonably can. Such organisations have been tremendously successful in numerous cities. A similar device is the co-operative medical society. A group of people from a cooperative, retain their own physicians by the year, and enjoy the unlimited right to consult him.

The American Medical Society has fought bitterly against procedure of these types. It has refused to permit its members to engage in such practice and has expelled some who have defied its regulations. Expulsion is an exceedingly serious matter since it brings into question the competence and professional standing of the physician. The United States Department of Justice recently brought action against the District of Columbia branch of the American Medical Association because of conduct of this sort, described it as a conspiracy “in restraint of trade”

State’s duty

The American Medical Association has no objection to co-operative or insurance plans to cover nursing-homes service only, and such plans are now widely popular in the United States. Hundreds of thousands of persons pay £2 annually and receive a maximum of three or four weeks’ of treatment in a long list of nursing homes. The medical societies have also endorsed a recent plan under which, with payment of a small fee, the patient is insured against the cost of a physician’s services during the first few weeks of any illness.

Such plans, however, do not satisfy the progressive among whom must now be reckoned President Roosevelt. They incline more and more to the belief that medical care is a public obligation and that when the individual cannot afford to pay for it the state should step in and give the service free. Such doctrine does not sound very radical in European ears, but in a conservative country like the United States, long dedicated to the doctrine of individual enterprise, it is an anathema to large numbers. The struggle that is now beginning will be one of the sharpest in the country’s history.