Cornell Univer sity L ibrary HD 7123.M4 1918^ Report of the Special commission on soci 3 1924 002 406 530 HD 7123 M4 1918 Massachusetts. Special Commission on Social Insurance. Report of the Special commission on social insurance « HD 7/2.3 M4 91? C.I THE LIBRARY OF THE NEW YORK STATE SCHOOL OF INDUSTRIAL AND LABOR RELATIONS AT CORNELL UNIVERSITY Cornell University Library The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924002406530 SEil3STB««*«»**«'«««>»^^ 244 REPORT SPECIAL COMMISSION ON SOCIAL INSURANCE. > I 'Januaky 15, 1918, BOSTON: WRIGHT & POTTER PRINTING CO., STATE PRINTERS, 32 DERNE STREET. 1918. m n/s C.I CONTENTS, Report. page Members, ............ 5 Letter of Transmittal, .......... 7 Resolve authorizing Appointment of the Commission, .... 9 Introduction, ........... 10 Summary of Work of Commission, ........ 13 Inspection of Mills, .......... 14 Report on Hearings, ......... 15 Conclusions of Majority, ......... 36 Statement by R. M. Washburn on Health Insurance, . . . .56 Views of a Minority regarding Free School Health, ..... 59 Statement and Suggestions of a Minority, . . . . . .61 Appendices. A. Report of a Special Inquiry relative to Dependent Families in Massa/- ohusetts receiving Mother's Aid, 1913-17, . . . .73 B. A Report on Dispensary Clinics in Massachusetts, particularly in Boston, 142 C. Schedule of Physicians' Fees, ........ 159 D. Summary of Data relative to Families visited by District Nurse Associa- tions, Public Welfare Boards, etc., ...... 160 E. A Study of 260 Industrial Plants in the United States showing the Extent and Character of Welfare Work in Industrial Plants, . . . 165 F. Chart showing Results achieved by Welfare Work in Department of Health and Sanitation, Norton Company, Worcester, Mass., . . 169 G. Letter from Secretary of Savings Bank Life Insurance, . . . 170 H. Proposed Legislation : — An Act to extend Voluntary Industrial Group Insurance, . . 175 An Act to provide Diagnostic Equipment for Clinics and Dispensaries and to encourage their Extension, .... . 175 An Act to provide Free Medical Treatment for School Children, . 176 A Resolve to establish a Commission to study the Question of a State System of Sickness Insurance for the Wage Earners of the Common- wealth, . .... . . 177 An Act defining "Personal Injury" as used in the Workmen's Compen- sation Act, so called, ......... 177 23623 MEMBERS OF SOCIAL INSURANCE COMMISSION. Senatok HERBERT A. WILSON of Boston, Chairman. Senator CHARLES D. BROWN op Gloucestek. Senator EDWARD F. McLAUGHLIN of Boston. Representative FRED P. GREENWOOD of Everett. Representative CHARLES B. FROTHINGHAM of Lynn. Representative BENJAMIN G. COLLINS of Edgartown. Representative CARL C. EMERY, of Newburtport. Representative ERNEST A. LAROCQUE of Fall River. Representative VINCENT BROGNA of Boston. Hon. ROBERT M. WASHBURN of Worcester. EVERETT MORSS, Esq., of Boston. JOHN D. WRIGHT of Boston, Secretary. Cf)e Commonttieaiti) of ^^aasatttusitm. To the General Court of Massachusetts. In accordance with chapter 130 of the Resolves of 1917 the Special Recess Commission on Social Insurance, appointed for the purpose of further investigating the extent to which poverty occasioned by sickness may be alleviated, medical care for wage earners and others of limited means may be provided, and measures to prevent disease may be promoted by in- surance, etc., has completed its work and respectfully presents the following report. Respectfully submitted, HERBERT A. WILSON, Chairman. REPORT OF THE SPECIAL COMMISSION ON SOCIAL INSURANCE. Chapter 130, Resolves of 1917. Resolve authorizing the Appointment or a Special Commission on Social Insurance. Resolved, That a special commission to be known as the Commission on Social Insurance, composed of three members of the senate to be appointed by the president, six members of the house of representatives to be ap- pointed by the speaker, and two other members to be appointed by the governor, shall sit during the recess of the general court for the purpose of further investigating the extent to which poverty occasioned by sickness may be alleviated, medical care for wage-earners and others of limited means may be provided, and measures to prevent disease may be pro- moted, by insurance. The commission shall undertake such investigations as to the health of wage-earners and the conditions under which they work, and as to existing systems of mutual, stock, fraternal, state, and other forms of insurance in this commonwealth and elsewhere as may be necessary to provide a sound basis for its recommendations, and shall submit a report, including drafts of any legislation which it may recom- mend, to the next general court, not later than the fifteenth day of Jan- uary. The state department of health, the bureau of statistics, and the insurance department are hereby directed to co-operate with the commis- sion and render such assistance as is compatible with the proper discharge of their respective duties. The commission shall have power to elect a chairman, secretary and other officers, to appoint sub-committees, and to employ assistance, clerical, expert or otherwise, as may be necessary. The commission shall have a room in the state house assigned for its use, and shall hold such public hearings as it may deem necessary, with the same powers to summon and examine witnesses as are conferred upon citj' councils and other bodies by the provisions of sections eight and nine of chapter one hundred and seventy-five of the Revised Laws. The commis- sion shall receive such sums for assistance, travel and other expenses, and for the compensation of its members, as shall be allowed by the governor and council. Approved May 25, 1917. 10 SOCIAL INSURANCE. [Jan. INTRODUCTION. In accordance with the provisions of the foregoing resolve the following persons were appointed to serve as members of the Commission on Social Insurance : — By His Excellency, Samuel W. McCall, Governor of the Commonwealth:— Hon. Robert M. Washburn of Worcester. Everett Morss, Esq., of Boston. By the President of the Senate, Hon. Henry G. Wells : — Senator Herbert A. Wilson of Boston. _ Senator Charles D. Brown of Gloucester. Senator Edward F. McLaughlin of Boston. By the Speaker of the House of Representatives, Hon. Channing H. Cox: — Representative Fred P. Greenwood of Everett. Representative Charles B. Frothingham of Lynn. Representative Benjamin G. Collins of Edgartown. Representative Carl C. Emery of Newburyport. Representative Ernest A. Larocque of Fall River. Representative Vincent Brogna of Boston. An organization of the Commission was effected on June 25, 1917. Hon. Herbert A. Wilson of Boston was elected to serve as chairman of the Commission, and John D. Wright of Boston as secretary. A subcommittee of three was named by the chairman to out- line and suggest the form the Commission's study should take. In order to familiarize themselves thoroughly with the sub- ject of health insurance, and determine upon the proper line of procedure and research, the members, immediately upon the organization of the Commission, held a number of conferences of an informal nature at the State House. Heads of organiza- tions, physicians and individuals were called in at these meet- ings and were requested to suggest to the Commission the best method of continuing the investigation inaugurated by the Commission of 1916. The first public hearing given by the Commission was held at the State House on September 5, and was confined to hear- ing the representatives of various labor organizations through- out the State. In all there have been given fourteen public hearings. The Commission visited the cities of Fall River, 1918.] SENATE — No. 244. 11 New Bedford, Lowell, Lawrence, Springfield, Pittsfield, Worces- ter and Lynn, and held evening public hearings in each. In accordance with the directions contained in chapter 130 of the Acts of the year 1917, the Commission also visited and in- spected ten industrial plants in which there are employed approximately 40,000 persons, in order to study at first hand the conditions under which the wage earners were laboring. Supplementing the conferences, the public hearings and the visiting of mills, the Commission authorized and directed certain inquiries to be made relative to the health and cir- cumstances of wage earners. The Commission takes occasion here to acknowledge its appreciation of the co-operation and valuable assistance rendered by the State Department of Health, the Bureau of Statistics, the State Board of Charity and the Massachusetts Savings Bank Life Insurance. For the three studies pre- sented herewith the Commission is especially indebted to the Bureau of Statistics, to Michael M. Davis, Jr., director of the Boston Dispensary, and the district nurse associations. The Commission caused a study to be made, first, of 3,516 cases to which so-called mother's aid was given through the medium of the State Board of Charity. Although the group is a selected one it has furnished reliable evidence upon which to found a study and analysis of the chief causes of dependency. The Commission was fortunate in securing the able assistance of Mr. Roswell Phelps, chief of the Labor Division of the Bureau of Statistics, to supervise the study, the results of which are presented later in the report, beginning with page 73. At the request of the Commission Michael M. Davis, Ph.D., director of the Boston Dispensary, very kindly, volunteered to make a study and survey of the dispensaries and clinics in the State for the purpose of determining the extent to which this type of medical service is available to the working people to- day. The Boston hospitals, because of their favorable location and the diverse nature of the cases applying to them for treatment, furnished considerable evidence for studies of particular groups. The more intensive studies, therefore, relate to cases recorded by the Boston clinics. The Commission 12 SOCIAL INSURANCE. [Jan. especially commends the report to the Legislature for its earnest consideration. The results of this study will be found in the Appendix, commencing with page 142. With the aid of the 113 district nurse associations in the Commonwealth the Commission through a questionnaire made a study of 5,210 cases for one week in October to ascertain the circumstances and other facts of interest in the families visited. (See page 160 of the Appendix for the results of this survey.) Early in October Mr. Everett Morss, a member of the Com- mission, was appointed to the Priorities Committee in Wash- ington, in connection with the administration of the war. The Commission consequently lost the counsel and valuable services of Mr. Morss, whose experience and training in the subject of social insurance while a member of a committee of the Boston Chamber of Commerce had been of great assistance to the Commission during the first months of its work. An invitation to the Massachusetts Commission to join in conference with other State commissions on social insurance moved the Commission to petition the Governor and Council for the necessary authority to leave the State. In compliance with the request of the Commission authority was granted by the Governor and Council, and the members of the Commission, with two exceptions, were present at the joint conference held in Philadelphia on Dec. 27, 28 and 29, 1917. Representatives and members of six State social insurance commissions were present at the meeting and participated in the discussions which took place. An interesting program covering the three days of the con- ference had been arranged by the American Association for Labor Legislation. Beginning with the first day the commis- sions met twice and three times daily for discussion and the exchange of notes. On December 27 two conferences were held, one in the morning, devoted to methods of investigation, followed in the afternoon by a discussion of methods in giving public hearings. In the evening members of the Commission were afforded an opportunity to hear Prof. Irving Fisher of Yale give a very interesting and instructive address on "Health and the War." On the second day of the conference the discussion of the 1918.] SENATE — No. 244. 13 previous day on the problems and methods of legislative investi- gation commissions was resumed. The forenoon was devoted _ to a "round table conference" on reports and the preparation of bills. In the afternoon there were addresses on topics of social welfare at the University of Pennsylvania, where a complimentary luncheon was served to the members of the State social insurance commissions and other organizations holding meetings in Philadelphia at the same time. Of the 6 commissions attending the conference only 2 were from States which had studied the question of health insurance for two years, namely, Massachusetts and California. Most of the other committees had been recently appointed. The informal nature of the discussions afforded an opportunity to the commissions to exchange ideas to the mutual advantage of all present. The Commission desires to express its thanks for the cour- tesies extended to it by the American Association for Labor Legislation, through whose good offices the success of the conference was assured. The Commission wishes to record here its appreciation of the valuable services of Mr. John D. Wright, its secretary, and its indebtedness to him for his untiring efforts and devotion to his work. SUMMARY OF WORK OF COMMISSION. In commencing its work the Commission sought to enlist the interest, aid and co-operation of all persons who would be most concerned in any measure to furnish relief to those most seriously affected by illness and its consequences. Previous to the public hearings wide publicity was given them, first, by written communications to all persons interested, and later by newspaper advertising and notices through the news columns in the various papers in the Commonwealth. Notwithstanding the fact that the stress of conditions due to the war detracted interest somewhat from the problem under consideration, the hearings of the Commission were generally well attended, and there was in most instances a generous and gratifying response to the Commission's invitation for expressions of opinions from those interested in the question of health insurance. 14 SOCIAL INSURANCE. [Jan. By reason of the express terms contained in the resolve under which the Commission of 1917 was created, it was clearly recognized that, unlike the Commission of 1916, which considered the questions of health insurance, old-age pensions, unemployment insurance and hours of employment in con- tinuous industries, this Commission had only one phase of social insurance with which to concern itself, namely, the problem which ill health among those of limited means presents to the State. In resimiing this study our Commission has earnestly sought throughout its investigations and deliberations to give careful consideration to every opinion expressed, and to weigh with equal judgment and fairmindedness the evidence presented by the public and the facts revealed through the several studies conducted by the Commission, the results of which are presented in another part of the report. 1. Inspection of Mills. As has already been stated, the Commission, previous to giving public hearings in the large industrial cities in the State, spent considerable time in going through the mills for the ex- press purpose of observing the conditions under which the employees labor. In making a selection of industries for inspection the Commission chose only those which would be representative of general working conditions in the State. The plants visited were chiefly the larger cotton mills in Fall River and New Bedford, in which two centers a large per- centage of the cotton goods used in the United States is manu- factured. Following the inspection of the cotton mills the Commission visited a woolen mill, said to be the largest in the world, in which approximately 6,000 people are employed. In these two industries there are employed fully 50 per cent, of the textile operatives in the State. A day was devoted to inspecting paper-making mills in the western part of the State, where there are some older and less modernly equipped plants. Foundry and machine plants employing 18,000 wage earners were also included in the torn: of inspection made by the Com- mission. By the courtesy of ofiicials at the several mills we were permitted free access to all departments, and ample time 1918.] SENATE — No. 244. 15 for observing working conditions and interviewing the em- ployees. A majority of the Commission is unanimous in reporting that the general conditions under which the wage earners work are in most cases very good, and satisfactory to the workers themselves. In the more modern textile mills, as well as in the machine industries, there are improved means of ventilation and lighting, which are in every case to be commended. There was observed a disposition on the part of the industries to provide rest rooms in the departments where women are employed. Employees are apparently better protected now against accidents, dangerous machinery and hazards in general than they were formerly. The establishment of model homes for the workers has been given a new impetus recently in some of our cities where in- dustrial corporations have erected single dwelling houses above the average construction and sold them to the employees on attractive terms. The period during which the Commission was engaged in investigating the various industries was ab- normal in some respects. The extraordinary demands made by the war had created more than the usual activity in many of the industries. With the increase in the cost of most com- modities there has been a general advance in wage rates averaging 10 per cent, or more in practically all the large plants visited. The pay of the employees generally was much higher than the Commission had been led to suppose. The shortage of labor reported in a great many cases has been partially responsible for bringing about an adjustment of wages apparently satisfactory to experienced workers. 2. Repobt on Hkarings. The Commission has summarized the opinions expressed in the hearings on the question of health insurance with reference, first, to the group which any health insurance measure would affect most vitally, — the so-called wage earners and others of limited means; secondly, to employers; thirdly, to physicians, insurance companies and various other organizations and persons included under the term "the public." The Commission during its deliberations and inquiry has 16 SOCIAL INSURANCE. [Jan. sought not to confine itself exclusively to any specific measure, and has endeavored in the numerous hearings to encourage the speakers to generaUze in their remarks on the subjects under consideration. Notwithstanding this, however, there has been a disposition on the part of a large number of those present at the hearings to confine themselves to a consideration in par- ticular of the provisions of the health insurance bills filed at recent sessions of the Legislature, and incorporated in the so- called American Association for Labor Legislation bill, which has been heretofore the subject of special discussion. Briefly, the provisions of this bill. House Bill No. 1074 of 1917, are as follows: Compulsory insurance is to apply to every wage earner in the Commonwealth whose compensation does not exceed $100 per month. The benefits are to apply to every case of sickness of employees, or of members of their families, and to accidents or deaths not covered by workmen's com- pensation acts. The minimum benefits are to consist of: — Medical, surgical, dental and nursing attendance and treat- ment; medicines and medical and surgical supplies; sickness benefit to the insured person or the dependent members of his family; maternity benefit; funeral benefit; medical, surgical and nursing attendance and medicines, and medical and surgi- cal supplies, for dependent members of their families. The expense of compulsory health insurance is to be con- tributed jointly by employers, employees and the State. The employer and employee are each to contribute 40 per cent, of the cost, and the State 20 per cent. The State is also to pay the administrative expenses. Reference will be made from time to time in this report to contributory health or sickness insurance and to non-contribu- tory health and sickness insurance. The terms are employed in order to distinguish between the form of insurance known as "contributory," where the employee is required to contribute together with the employer and the State, and that called "non-contributory," which refers to the health or sickness insurance favored by a large number of labor organizations in the State, which provides either for the State and employer to pay the cost, or for the State alone to carry the burden, but to 1918.] SENATE — No. 244. 17 which the employee in no case contributes directly. In both instances, however, the insurance is assumed to be compulsory on the parties carrying it. Labor's Position. At its second meeting after organization the Commission called into conference certain of the leading labor men in the State. It was suggested at this conference that the Commission might best learn the sentiment of the various organizations throughout the State by arranging a public hearing far enough in advance so as to give the local branches of labor an oppor- tunity to discuss the question of health insurance at a regular monthly meeting, and to delegate some one or more of their members to attend the public hearing. In accordance with this suggestion the Commission im- mediately arranged for a hearing to be given early in Septem- ber, and letters were sent out to the various central labor unions in the State, asking them to co-operate in bringing the hearing to the attention of the local labor organizations, with the suggestion that the matter be taken up for discussion and members be delegated to attend the public hearing in Boston. The Commission, moreover, advertised the hearing throughout the Commonwealth in all the leading newspapers. As a result of this publicity and the correspondence with the labor exchanges there was a good attendance at the first hear- ing held at the State House on September 5. In all, twenty- two labor men appeared and spoke on the subject of health insurance. Most of them had been instructed in advance by their local organizations. Practically all who appeared at this time expressed themselves in favor of some form of health insurance, but stated that they were opposed to a so-called "contributory" scheme. They expressed themselves in favor of a non-contributory form of insurance, if any. Several of the labor men at this hearing objected especially to the compulsory feature which they had noted in the health insurance bills recently proposed in the Legislature. One or two advised a further study of the question before any form of insurance was undertaken. There was a desire on the part of 18 SOCIAL INSURANCE. [Jan. at least two men appearing at this hearing to have an investiga- tion made in respect to some of the more dangerous trades in which they beheved there was a greater risk to a workingman's health than in most occupations. They favored the extension of the Workmen's Compensation Act to cover more adequately those diseases directly attributable to occupation. Those fa^ voring a form of health insurance to which the wage earner would not be required to contribute anything were somewhat divided in their opinion as to who should bear the burden of the expense. Part of them felt that the employer and the State jointly should bear the burden; others believed it was the function of the State alone, and that the funds required to carry on the insurance should be raised by taxation. Only 1 out of 22 representatives who testified at this time cared to go on record as favoring a contributory plan of in- surance. On being questioned he stated that while he might personally favor contributory insurance, he felt, however, that a majority of the members of his union were opposed to any form of contributory health insurance. It was suggested by one delegate that higher wages and better working conditions would alleviate and solve the sickness problem. An analysis of the sentiment of the delegates expressed at this first hearing of the Commission would indicate that labor was agreed only on one point, namely, the desirability of health insurance. In addition to the objections stated above there were others made to any form of health insurance which would be com- pulsory and which would require contributions on the part of the employee. Some thought the obstacles in the way of health insurance were insurmountable, and expressed themselves as believing that notwithstanding the success of health insurance abroad, which the advocates of health insurance maintain it has had, it is not adaptable to American needs. There was one who objected to health insurance on the ground that it was class legislation, inasmuch as it taxed a certain class of individuals without any direct return. It is interesting to note that those who most strongly ob- jected to any form of health insurance at this time were those leaders in the labor movement who, it seemed to the Commis- 1918.] SENATE — No. 244. 19 sion, had given most thought and study to social insurance. As evidence, we believe, of the sentiment prevailing in labor circles throughout the country, we quote from the recent address of the president of the American Federation of Labor:/ — This fundamental fact stands out paramount, that social insurance cannot remove or prevent poverty. It does not get at the causes of social injustice. The efforts of trade organizations are directed at fundamental things. They endeavor to secure to all the workers a living wage that will enable them to have sanitary homes, condi<;ions of living that are conducive to good health, adequate clothing, nourishing food and other things that are essential to the maintenance of good health. In attacking the health problem from the preventive and constructive side they are doing in- finitely more than any health insurance could do which provides only for relief in case of sickness, and yet the compulsory law would undermine the trade-union activity. There must necessarily be a weakening of in- dependence of spirit and virihty when compulsory insurance is provided for so large a number of citizens of the State. The trade-union movement does not detract from the power of the oppor- tunity of wage earners. On the other hknd, methods for providing social insurance delegate to outside authorities some of the powers and oppor- tunities that rightfully belong to the wage earners. At first only a limited amount of authority and power may be delegated to and exercised by the governmental agent, but the application of even that little power con- stitutes a limitation upon the rights and freedom of wage earners and creates a situation which has in it the germs of tyranny and autocratic power. Governmental power grows by that upon which it feeds. Give an agency any political power and it at once trips to reach out after more. Its effectiveness depends upon increasing power. Compulsory social insurance cannot be administered without exercising control over wage earners. This is the meat of the whole matter. Industrial freedom exists only when wage earners have complete control over their labor power. Compulsory social insurance is in its essence undemocratic. The first step in establishing social insurance is to divide people into two groups, — those eligible for benefits, and those considered capable of caring for them- selves. The division is based upon wage-earning capacity. This govern- mental regulation tends to fix the citizens of the country into classes, and even divide the wage workers into classes, and a long-e'stabHshed insur- ance system would tend to- make these classes rigid. There is in our country more voluntary social insurance than in any other country in the 1 Samuel Gompers, address at annual meeting of National Civic Federation, New York, Nov. 9, 1017. 20 SOCIAL INSURANCE. [Jan. world. We have institutions whereby voluntary insurance can and wiU be increased. The workers of America adhere to voluntary institutions in preference to compulsory systems, which are held to be not only im- practicable but a menace to their rights, welfarte and their liberty. Health insurance legislation affects wage earners directly. Compulsory institu- tions will make changes not only in relation to work, but in their private lives, particularly a compulsory system affecting health, for good health is not concerned merely with time and conditions under which work is performed. It is affected by home conditions, social relations and aU of those things that go to make up the happiness or the edsolation of life. To delegate to the government or to employers the right and the power to make compulsory visits to the workers under the guise of investigating health conditions, is to permit those agencies to have a right to interfere in the most private matters of life. It is, indeed, a very grave issue for workers. They are justified in demanding that every other voluntary method be given the fullest opportunity before compulsory methods are even considered, much less adopted. The trade unionists who have con- sidered the problem and expressed an opinion have advised against such compulsory institutions. At the nine hearings held outside of Boston in the principal industrial cities, representatives of labor appeared to give the views held by the several organizations which they represented. The opinions expressed at these hearings outside of Boston were practically in accord with those voiced at the first hearing held in Boston. There was nearly unanimous expression in favor of sickness insurance, but opposition to any plan under which the worker would be compelled to contribute. It was admitted by a few that upon further study of the question they might possibly change their views with regard to the contributory feature. To sum up, the sentiment of organized labor on the question of health insurance is prac- tically unanimous in desiring only one type of health insurance, namely, non-contributory. It seems to a majority of the Commission that this decision on the part of most of the labor unions has been reached only after careful study and thought. The matter has now been debated in the State for nearly three years. The question has been discussed at considerable length in labor conventions held during that time, and it is interest- ing to note here a resolution passed at one of the most recent 1918.] SENATE — No. 244. 21 State conventions of labor in anticipation of the then approach- ing Constitutional Convention. Resolved, That if health insurance should be found to be unconstitutional, the Executive Committee is instructed to have a constitutional amend- ment brought before the Constitutional Convention making a non-con- tributory system possible in this State. In most cases the labor representatives were questioned with regard to the extent to which their members were already insured against illness. The majority of the men stated that their members generally carried some form of insurance, and that there was a disposition on the part of the workmen now to insure themselves more than they had in the past. Employers' Position. The second hearing which the Commission gave at the State House in Boston was designated a hearing for employers, and it was so advertised. Owing to the fact that a number of employers and representatives of employers who had expressed their intention of attending this hearing were at a convention of Chambers of Commerce in another city on the same day, there was not the response which the Commission anticipated. One of the largest associations of employers in the State, however, sent a representative to oppose health insurance. He stated that the attitude of the manufacturers was that the question had not as yet received sufficient study to justify any legislative action or definite recommendations on the question. As yet, he said, the manufacturers felt the subject was in its theoretical stage. Employers questioned the advis- ability of the State's embarking upon any insurance scheme so vast as the one proposed, and he believed that conditions in the various industries at the present time were such as not to require any such extreme measure. His association felt strongly that the question should be held in abeyance at least until the war was ended, in order that industries and individuals also might be left as free as possible to give their services to the government. There was a serious question, he said, whether 22 SOCIAL INSURANCE. [Jan. or not the increased tax which would inevitably result from a system of State health insurance would accomplish as much as its advocates maintained. A great deal of welfare work is already being done, he said, in various industrial plants, and this work is being rapidly extended, not only through the Commonwealth, but through the country as well. The only other person who appeared at the hearing for employers was the head of a concern employing about 125 men and women. He stated that he favored some sort of health insurance. He believed that health insurance benefits not only the workingman but the whole community. It had a tendency also, he thought, to prevent disease. Ques- tioned as to what sort of a system of insurance he favored, his reply was that a contributory system requiring contribution on the part of employees, employer and the State would probably prove the most feasible. At the hearings given outside of Boston there was nearly always a good representation . of employers, who in most in- stances freely expressed their views on the question of health insurance. They were practically unanimous in voicing their opposition to the scheme. Some of the principal objections put forward at the various hearings given in the chief industrial cities of the Commonwealth were as follows: — 1. No exigency exists for health insurance in the State. 2. Employers are rapidly improving working conditions in their factories. 3. Welfare work and mutual benefit societies exist generally, permitting employees to insure themselves at their option. 4. The adoption of a health insurance scheme similar to those prevailing in Europe would in effect be taxing the people for the indiscretions of the beneficiaries. 5. The State should concentrate its efforts on preventive work rather than on the attempt to cure diseases through insurance. 6. The Workmen's Compensation Act has already taken some liberty from the individual wage earner, and health insurance would take more. 7. The tendency of health insurance would be to pauperize the workers. 1918.] SENATE — No. 244. 23 8. Health insurance is not suited to American needs. 9. It is economically not a success abroad. 10. Its cost is prohibitive. 11. It encourages malingering. 12. Self-respecting labor does not desire it. In addition to these objections, registered by the em- ployers and their representatives who appeared at the hearings of the Commission, one large association of manufacturers and employers in western Massachusetts, which has since met and discussed the question of health insurance, has ad- vised the Commission that the association is opposed to the proposition. It is asserted by some of the employers that better welfare work can be done voluntarily than through compulsion. A prominent manufacturer in England, who had favored health insiu'ance and who had worked for the passage of the English act, is quoted as saying to a Massachusetts manu- facturer that it was a national question, and he maintained that for any single Commonwealth to establish a measure of this character would not favor but disrupt the industrial con- ditions in that State. With but few exceptions, most of the large manufacturers stated that mutual benefit associations were being maintained in their plants. In the case of some of the larger concerns the officials had gone further and established free dispensary service for the benefit of their employees. Some of the manu- facturers stated that in their opinion manufacturers are better equipped to carry on this welfare work than the State. One or two expressed themselves as not seriously opposed to any health insurance measure, provided it could be drawn so as to do justice to all concerned. Emphasis was laid on the fact that sickness insurance abroad had tended to increase malingering, and that statistics in- dicated it was not a success in the foreign countries where it is in operation. There were certain localities in which it appeared from the testunony given at the hearings that welfare *work for em- ployees was being carried on to a greater extent than in other parts of the State. The testimony given indica,ted to the 24 SOCIAL INSURANCE. [Jan. Commission, however, that there is a growing interest and disposition on the part of all employers to undertake 'Work of this nature in some way or another. Physicians' Position. An early efPort was made to enlist the interest of the phy- sicians in the State, and the members of the medical profession have appeared at the hearings in greater numbers and evinced a keener interest in the question of health insurance than any other one group of persons. The two hearings given at the State House exclusively for physicians, as well as the hearings given outside of Boston, were very well attended. As a rule, the physicians were inclined to participate in the discussion of the question under consideration by the Commission, and to furnish such facts as they could relative to local conditions and affairs. In addition to representatives of medical societies and local districts, a great munber of physicians appeared in an individual capacity, and in such cases expressed their personal views on the subject. The Commission in this manner has had the opportunity of learning from a very representative number of physicians many interesting facts as to local health conditions in the State, as /Veil as their personal views on State health insiuance. Previous to visiting several of the large cities in which hear- ings were given, letters briefly stating the purpose and subject of the hearings were sent to the local physicians, to assist them, perhaps, in forming some opinions, and to enable the Commis- sion to arrive at some conclusions respecting conditions in each community. In these letters four questions were sub- mitted, as follows : — 1. Shall the State insure its citizen wage earners? If so what is the best scheme of insurance? 2. Is the cost of medical care and attention beyond the reach of the ordinary workingman to-day? 3. To what extent are the wage earners able to avail them- selves of free clinics in the State? 4. How can the State aid further in extending the work of preventive medicine? 1918.] SENATE — No. 244. 25 It was obvious from the testimony of many of the physicians that the question had been given serious study. As a whole, they seemed inclined to consider it from a liberal point of view, and many expressed their willingness to withdraw their op- position to any form of sickness insurance, provided it could be demonstrated beyond question that the scheme would actu- ally benefit the wage earners and improve health conditions. Of the hundred or more physicians testifying, only two were ready to declare themselves in favor of insuring the wage earners against disease. As to the best means of accomplishing it, these men were divided in their opinion. The other phy- sicians believed the workers were already generally pretty well insured through various orders and agencies. The med'cal profession as a whole maintains that the cost of medical care and attention is not beyond the means of the ordinary workingman to-day, and that charges in Massachu- setts are not excessive. To substantiate their contention they have submitted a fee schedule, which compares very favorably with the fees charged for the same service in other States. This schedule will be found on page 159 of this report. One physician with thirty years' experience in a rural com- munity contended that the best medical care obtainable was within the reach of all citizens in his locality. If they were unable to pay, he said, treatment was furnished without cost. Eighty per cent, of his patients, however, were able to pay their bills in full. In response to the last two questions, various theories were advanced as to methods by which the present agencies could be made more effectual than at present and medical service made more available to the working people. The proposal that the free clinics in the State be extended was approved in most instances. On pages 151 and 158 will be found a survey showing the niunber and location of free clinics and dispensaries in the Commonwealth. The physicians, however, believe it unwise to enact any health insurance bill at the present time. Many of them were reluctant to express their opposition to legislation of this kind lest their position be misunderstood. It was the opinion of most of them that there was not the need in the Common- 26 SOCIAL INSURANCE. [Jan. wealth for health insurance which some maintain. Medical service, they say, is now available to the workingman and to those unable to pay either a hospital fee or a physician's fee. In case of inability to pay, both are provided without cost. Nevertheless, the doctors regard it highly important that the existing health agencies be extended wherever possible, and many of them advocated larger appropriations as a more adequate solution of this problem. Following the series of hearings given in. cities outside of Boston, the Commission sent out in November a request to city physicians and health officials to meet at the State House for the purpose of discussing local health conditions and determin- ing, if possible, the extent of illness and its relation to destitu- tion in our larger cities. A number of health officials responded to the appeal, and the Commission was able to gather some additional information and facts of value. It was brought out at the hearing that a few of the larger cities of the State have out-patient clinics connected with their hospitals, where people can obtain medical service at a nominal fee, or gratuitously, when they have no means. In addition there are tubercular clinics. Medical inspection in schools is carried on to some extent, but this work lacks uniform regu- lation, and some of the physicians were of the opinion that it could be made more efficient than at present by State regulation. The Commission was impressed with the interest and en- thusiasm manifested by the doctors in local health affairs, and by their agreement that though health conditions could doubt- less be greatly improved, at present the situation was being well handled. It was the general belief of the local health officials present at the last hearing given by the Commission that health conditions were steadily improving. This was due for the greater part, it was stated, to better and more efficient preventive work. In this connection it is interesting to note, from a comparison of the figures submitted by the city physician of New Bedford of cases of tuberculosis treated at the local sanatorium with the number of operatives employed in the mills from 1915 to 1917, a decrease of nearly 200 per cent, in the number of mill 1918.] SENATE — No. 244. 27 operatives treated for tuberculosis in that time. In 1915 there were treated at the sanatorium 210 cases; of these, 120 were mill operatives. In 1916 there were 225 cases; mill operatives numbered 83. The cases treated in 1917 were 245; only 44 of these were mill operatives. Some of the physicians frankly admitted that one of the reasons for their opposition to sickness insurance was that they had suffered a serious economic loss as a result of the passage of the Workmen's Compensation Act, and it was their belief 'that a similar loss would result from the passage of a health insurance bill. Physicians testified to the great number of rejections, which reached as high as 50 per cent, in some cases, among the men examined under the draft for the national army. One doctor believed that not more than 6 or 8 per cent, of the physical defects found among those rejected could by any means be traced to industrial conditions. Underweight was said to be the greatest single cause of rejection; defective vision and poor teeth ranked second. It was the opinion of the examining physicians that a large percentage of the physical defects found in draftees was preventable. Compulsory physical training in the schools was suggested as the best means of improving the physical condition of our young men. Serious doubt was expressed by a great many physicians as to whether health insurance would reach the class most sorely in need of help, and whether payment of benefits to those whose illness entailed loss of wages would tend to prevent sickness. "The term 'health insurance' is capable of misin- terpretation," said one prominent physician. "To pay a man an indemnity for time lost in sickness is not insuring him against sickness in any way. It may make his lot while sick more comfortable. The matter of keeping well," he said, "is largely a question of hygiene, and hygiene is largely a question of education." The medical profession as a unit has asked that the matter of health insurance be given more study before the enactment of any legislation. They contend that it will interfere seriously with the relations between the physician and the patient, and that it will tend to discourage men from entering the profession. 28 SOCIAL INSURANCE. [Jan. These sentiments of the medical fraternity on the question of social health insurance in Massachusetts appear to be reflected generally throughout the country, if we are to judge from the following resolution passed at a convention of the American Medical Association held in New York City on June 6, 1917: — Resolved, That after full discussion and careful consideration of the subject the section on Preventive Medicine and Public Health of the American Medical Association hereby instructs its delegate to the_House of Delegates of the American Medical Association to oppose the scheme for compulsory health insurance in every way possible. In this connection a member of the American Medical Association, in submitting the resolve, made the following comment to the Commission: — This resolution was passed after fuU and careful discussion of health insurance. Delegates were present from all the States in the Union; hence their attitude can be taken as nearly the attitude of all the medical societies in most of the States. Pharmacists' Position. A State association of retail druggists, said to have a mem- bership of about 1,500 registered pharmacists, aligned itself with those opposing health insurance, and through its repre- sentatives who appeared at one of the public hearings given by the Commission asked to be recorded as opposed to any plan of State health insurance. The objection of the druggists seemed to be based mainly on the theory that a health in- surance bill would seriously interfere with the business of the druggists, and would tend to center the trade in a few clinics and dispensaries. The representative of the State Association of Druggists stated that the National Association, with a mem- bership of 40,000 retail druggists scattered throughout the country, had also recently recorded its opposition to the principle of sickness insurance. As an indication of the general feeling among druggists throughout the country, an abstract from the "Journal of the American Pharmaceutical Association" of October, 1917, was submitted at the hearing, from which is quoted the following: — 1918.] SENATE — No. 244. 29 If compulsory health insurance becomes a fact it will not only be a public menace but it will be the greatest blow ever suffered by the drug trade of America. I am speaking of the plan in its present form. If it can be so modified and improved as to become a public benefit instead of a public danger, and particularly if the compulsory feature can be eliminated, druggists and other public-spirited citizens will desire to support it. The National Drug Trade Conference and the American Drug Manufacturers' Association have declared their opposition to the movement until time can be afforded for a more careful study of the situation, and this is the attitude that should be taken by the American Pharmaceutical Association and by all other branches and divisions of the trade. Insurance Companies' Position. A number of representatives of insurance companies attended a public hearing set apart especially for them on September 12. As might be assumed, the companies engaged in commercial insurance view with some alarm the entrance of the State into their particular field of business, and are, therefore, opposed to the principle of sickness insurance by the State. While it appears that this opposition is due mainly to the fear of jeop- ardy to their business, it is interesting to note, nevertheless, some of the objections voiced by the opponents at the hearing. At one of the hearings there was pointed out an error in statement made by the former commission relative to the amount paid for industrial insurance in the State and the amount returned to the policyholders. This Commission, therefore, has requested the Insurance Commissioner to prepare a statement correcting these figures and also those given in the message of the Governor to the Legislature of 1917. The statement a*s submitted by the Insurance Commissioner is presented herewith : — A Statistical Eeeoe in the Rbpobt of the Special Commission on Social Insueance.^ The passages containing the error are as follows; — Statement of Allison G. Cathebon, Eden K. Bo-wseb, Frank S. Faenswobth AND Haket C. Woodill. The existence of numerous voluntary plans of insurance shows a general belief in this principle. Even industrial insurance private corporations furnishing only a small death benefit, hardly more than enough for burial, and with the high » House Document No. 1S50, February, 1917. 30 SOCIAL INSURANCE. [Jan. premium rates required by the expenses of weekly collections, has been deemed of such value by the wage earners of the Commonwealth that in the last insurance year they paid in premiums the sum of $12,251,000, though the losses paid were only $4,094,000. Of the $12,251,000 paid for industrial insurance in Massachusetts in 1915 by wage earners, about $8,000,000 did not come back in benefits. WhUe some of this burial insurance is for children, and might be continued under the proposed health insurance, a considerable part of this would be met by the funeral benefit under the proposed law. The wage earner is also meeting to-day the entire expense of his medical treatment, except so far as provided by charity, and he is struggling along as best he and his family can under the burden brought by sickness when his wages stop. From a financial standpoint the employee will gain instead of lose, both directly and indirectly, by the proposed system. If the wage earners of the Commonwealth can pay over $12,000,000 a year, chiefly for the expensive funerals which the $4,000,000 returned to them by indus- trial insurance provides, even a much larger cost than $23,000,000 for the proposed plan of health insurance would appear to be justified if necessary. Statement of John P. Meade and Edwakd G. Morbis. That the working people of Massachusetts are keenly aware of the necessity of protecting themselves against conditions that undermine the stability of the home is evidenced by the fact that they paid over 812,000,000 in premiums for industrial insurance during the year 1915 in Masse,chusetts. What is very significant in connection with this statement is the fact that they received but $4,000,000 in actual cash benefits in return. In addition to the above, Governor McCall has incorporated a reference to these statistics in his 1917 inaugural address, as foRows: — This condition would seem to demand some form of insurance which would probably need to be compulsory in order to be effective. For what ia classified generally as industrial insurance, premiums were paid in Massachusetts in 1915 to the amount of $12,251,000, while the losses paid were only $4,094,000, or more than $3 in premiums to each dollar of loss. An insurance made up of small policies, with the attendant expense of soliciting it and of making collections usually weekly or monthly in small sums, is "loaded" with an enormous charge for administration. This charge could be very largely done away with under a system of compulsory State insurance, and any profits of the business would be entirely saved to the insured. A serious error has been made in quoting the above figures in this manner, resulting in a gross exaggeration of the cost of industrial insurance to the workingmen of Massachusetts. Although, as stated, only $4,094,000 was paid by the industrial companies for Massachusetts claims, approxi- mately 12,587,000 ^ was credited to the policyholders' reserve account during the same period of time, over and above all withdrawals therefrom and exclusive of the interest credited to maintain reserve. In addition to this amount approximately 1535,000' was paid in cash for surrendered policies, and nearly $1,061,000' was returned to the policyholders in the form of dividends. It would appear, therefore, that the total payments ' These figures are based upon percentages obtained from total business of industrial com- panies operating in Massachusetts. 1918.] SENATE — No. 244. 31 to the insured or beneficiary in cash or credits amount to approximately $8,277,000 instead of $4,094,000. An idea of the relative expense of carrying the various forms of insurance may be obtained from examination of the following expense ratios taken from the 1917 insurance report: — Per cent, of expenses to gross premium income: — Ordinary insurance, . . . . . . . 18.08 Weekly premium insurance, . . ... 32.80 Savings bank insurance: — Paid by the banks, . . . . . 9.35 Paid by the State, ... . . . 8.25 17.60 Ray a. Whebleb, Assistant Actuary. Jan. 7, 1918. In their reasons for opposing State sickness insurance it appears the representatives of the insurance interests were agreed on certain main points. In view of the nature of their business, and the extent to which general disability insurance is carried on in the Commonwealth, many of the companies maintained that it would be unfair to enact any law which has in effect the contemplation of establishing new carriers and local distributing agencies for insurance funds. Since the Commonwealth would- be able to furnish insurance at cost, the enactment of such a measure, it is claimed by the insurance interests, will result in excluding from the field of insurance a great many companies the major part of whose business is writing health and disability insurance. It was further maintained by those who appeared in opposi- tion to any form of State health insurance that the system had been demonstrated to be not a success abroad. By way of ' confirmation it was stated that social insurance had been introduced in Europe as a corrective measure to eliminate much of the illness and suffering among the underpaid wage earners. Investigation had proved that the results are not what were expected. It was asserted that the situation in Germany, the first country to introduce a scheme of sickness insurance, is, after thirty years' experience, practically unimproved as far as general health and economic conditions are concerned. One representative who appeared at this hearing stated: — 32 SOCIAL INSURANCE. [Jan. A study of all countries in which social insurance has been enacted will show that want, misery and suffering still exist, and in practically the same degree. The records show that one room for each family in the city of Berhn is all that 55 per cent, of the population can afford, and Berlin is representative of the State. Other grounds upon which the insurance companies based their objections to health insurance are : — 1. The test of any economic measure is the net profit result- ing. It cannot be shown that any net profit has ever accrued from sickness insurance. 2. The development of individualism will be discouraged. 3. Health insurance is paternalistic. 4. If such a measure is passed and the experience of other countries is repeated there will be increased sickness and of longer duration than before. An association of fraternal organizations comprised of lodges, secret orders, etc., with a membership of about 200,000, through its representative asked to be recorded as opposed to health insurance. The nature of the opposition of this association is perhaps best revealed by the testimony of this representative, to the effect that individual members of the fraternal organiza- tions would lose their independence if they were subject to a compulsory health insurance act, and that the organizations themselves, which are now in a prosperous condition, would receive a body blow if their income were diverted to the agency of the State. In addition to those who in person voiced their opposition to State health insurance at the public hearing given for the insurance companies there were a number of insurance com- panies doing mutual and stock business in Massachusetts who submitted similar objections to the Commission in writing. We submit an excerpt from a statement presented by one of the large accident and health insurance concerns in Boston, which sets forth briefly the position of many of the insurance interests. At the present time there are in America approximately 250 insurance company and fraternal societies (representing over 8,000,000 members] selling health insurance to the laboring classes on plans which permit of th( 1918.] SENATE — No. 244. 33 payment of premiums in small weeily ox monthly payments. This health insurance is so inexpensive as to be within the reach of all, and the whole business in Massachusetts is under the direct supervision of the Massa- chusetts Insurance Department. For illustration: a laboring man may to-day purchase, for a small charge of from 25 to 80 cents a month, health insurance protection which will pay him from $25 to $100 a month (depend- ing on his occupation) during disability from sickness. As a rule, such health insurance and the combined premiums usually run from $1 to $1.25 a month. There are many ihillions of dollars of such industrial accident and health insurance in force to-day, the result of over twenty years of strenuous effort on the part of private insurance companies and their thousands of sohcitors to make this so-called "bread and butter" insurance popular among the laboring classes. We contend that compulsory State health insurance is unjust to insur- ance companies and laboring men alike. It gives the State the very kind of a monopoly which the State itself has always condemned and forbidden among its own citizens. It arbitrarily forbids private citizens the right to compete with the State for business. It contemplates the confiscation of one of this country's great business enterprises which has taken years to develop, and the transfer of its management to inexperienced, ever- changing State officials. If health insurance is a good thing for the laboring man to buy, he should be urged (but not compelled) to buy it, but he should have the liberty to purchase that health insurance from whomever he pleases. The moment that the State steps in and says, "You are compelled to buy health insur- ance (whether you want to or not), and, furthermore, you are compelled to buy it from me (whether you want to or not)," — that moment will breed the birth of an anti-government sentiment in this country which will ultimately wreck the foundation stones of our great democracy. If the State is to be allowed to take up the transaction of business at all, then, in justice to its own citizens, it should enter the field in competition with private interests, be subject to the same business hazards and ha- bilities, and forced to "make good" in a fair, open, honorable race of merit. Some of the insurance companies are engaged in welfare work in the Commonwealth which appears from all accounts to be of a constructive and preventive character, and is being carried on apparently with quite a degree of success. The majority- has thought it worth while to set forth more at length in another part of the report additional facts regarding this phase of health work. 34 SOCIAL INSUEANCE. [Jan. General Public's Position. Supplementing the divergent views held by these five groups of individuals, several people appeared in an individual capacity and discussed the best means of relieving or eradicating the effects of illness. They came from different professions and walks of life, and included ministers, professors, lawyers, nurses, public officials and others. As might be expected, there was a, greater variety of opinion expressed by them than there had been from group representatives. Among them were also students of social conditions and health insurance, who appeared to have given the most thought to this question. Several of the latter were members of the Massachusetts Health Insurance Committee, a committee which was formed during the past year by local members of the American Associa- tion for Labor Legislation, from which association comes the main support given to the so-called "model health insurance bills" filed in recent years with State Legislatures. In contradiction to much of the testimony already presented in a part of this summary, it was asserted by the advocates of such legislation that the successful operation of health insurance could be demonstrated beyond question. Statistics were quoted in certain instances in support of the contentions made for the compulsory contributory plan, and reports of committees and authorities were submitted at some length tending to bear out their statements. The cost of health insurance in the State of Massachusetts has been computed at various figures; there is a division of opinion as to what the cost of putting the scheme into operation would be; however, notwithstanding the expense, which is problematical, the advocates of the bill point out that illness is already costing the State a great amount of money, which they insist should be taken into account in considering the cost. The advocates of sickness insurance maintain that it will accomplish more than any other social insurance measure in solving the problem of illness and its consequences among the working people. They assert that a real demand and necessity exists for the measure, and that the demand is growing. It is declared by those favoring compulsory health insurance that 1918.] SENATE — No. 244. 35 voluntary insurance is a failure, since people either fail to avail themselves of the present opportunities, or through lack of means are prevented from insuring themselves against illness. Even the most ardent supporters of compulsory health insur- ance in Massachusetts, however, urge upon the Commission the importance of further study before recommending the enact- ment of legislation. In answer to the critics of the bill, who' charge that it is not a success abroad, the proponents maintain that it has greatly improved health conditions in the countries where it is now in operation, and they quote various authorities to substantiate their statements. To prove that the British act has not been a failure, advocates of health insurance have read at the hearings of the Commission excerpts from a report of a special commission appointed to investigate the working of the law throughout the British Empire, which for the most part comments favorably on the success of the measure. Among those endorsing the principle of health insurance there is a division of opinion, again, as to the practicability of making it both compulsory and contributory on the part of the employee. There were those who desired to be recorded in favor of health insurance who admitted that they had not given much thought to the subject, but that they considered it a step in the right direction. Those who objected to any sickness insurance legislation urged various reasons for their point of .view. Some maintained that the present agencies are doing excellent work within their limited scope, and recom- mended the extension of free dispensaries and clinics and the continuation by the State of its present work of prevention. It was the prevailing opinion among them that to pass insur- ance legislation of so broad a character at this time would result in diminishing the effectiveness of the present system. SOCIAL INSURANCE. [Jan. CONCLUSIONS OF MAJORITY. An analysis of the evidence, a synopsis of which has been esented in the foregoing pages, reveals no growing demand the Commonwealth for compulsory contributory health leg- ation. On the contrary, if we are to judge from the ex- irience of the former Commission considering this question, ere appears to be an increasing hostility to this type of in- rance on the part of representatives of large aggregations of iividiuals who, in the final analysis, would be most vitally Fected by such a measure. The so-called compulsory contributory system of health in- rance has few supporters. There appear to be two serious istacles to the enactment of legislation of this character, ,mely, the united opposition of employer and employee to the heme, and the difficulties presented by the constitutional pects of the question. The so-called non-contributory system has the endorsement labor, — a strangely apathetic one, however. The majority the Commission feels that it cannot recommend a plan of is character which is without precedent anywhere as far as has been able to determine, and which is manifestly inequi- ble in its apportionment of the cost. We find among those who were formerly disposed to favor mpulsory sickness insurance a growing suspicion, amounting absolute conviction on the part of a few, that the, compul- ry feature of such insurance infringes on the rights of the lividual. A study and comparison of the pvidence presented the former Commission and our own further confirms us in r opinion that there is much less inclination at the present le to look with favor upon compulsory health insurance in 3 State than was the case a year ago. Moreover, opposi- n to compulsory insurance, judging from the numbers pres- t at the hearings and the nature of their testimony, appears have been stronger this year than last. It is natural to lume that the medical fraternity is interested in raising the .ne of the health of the community, but the majority ards it as significant that the profession as a whole asks for legislation. 1918.] SENATE — No. 244. 37 No law can be created without public sentiment or enforced without the belief of the public behind it. Ih our opinion the effect of enacting legislation of this character would not be conducive to the mutual well-being and good feeling that exists in most industries at the present time. To force all employers into contributing under a bill of this kind would mean a cessa- tion of much of the excellent welfare work that many of them are now maintaining or rapidly initiating into their plants. The Commission has been given certain facts and figures which indicate some of the excellent results obtained in this Commonwealth by means of efficient preventive work. The character of this branch of our health work is unquestionably the highest in the world. Our health officials, however, grant that limited appropriations alone prevent this system of health conservation from being extended and made even more effective than it is at the present time. The solution of the problem of sickness and its consequences has for a long time presented economic difficulties seemingly insurmountable to social students. This Commission, during the limited time it had to study the question, has had manifold evidence of some of the perplexities which are involved in the question. Investigation and inquiry reveal the fact that a large portion of the wage-earning class is without disability insurance other than workmen's compensation. There is, how- ever, among these uninsured a large group which, through natural vigor and inherent physical well-being, is not seriously affected by sickness and its consequences. The majority can- not disregard the objection put forward by labor bodies and others that compulsory contributory health insurance is class legislation, inasmuch as it taxes one class of citizens, the in- herently healthy, for the benefit of the smaller but less for- tunate group on which the burden of illness falls. After serious consideration of the evidence submitted at the various hearings, and of the several studies undertaken in its behalf, the majority has reached its conclusions, and does not feel justified in recommending a bill to establish a system of compulsory State health insurance within the Commonwealth. 38 SOCIAL INSURANCE. [Jan. VOLtTNTAKY HEALTH InSUKANCE. As a means of relieving the burden which illness often im- poses on those of limited means, the majority of the Com- mission submits recommendations which it believes will result in the extension and more effective administration of existing voluntary agencies in the Commonwealth. It is our opinion that an ultimate solution of the sickness indemnity question may be partially reached at least through the growth and development of voluntary industrial mutual benefit associa- tions now in operation. The form of voluntary insurance engaged in by the Massachusetts Savings Bank Life Insurance, which has for some time been organizing group insurance in industrial plants, presents great possibilities. To equip the Massachusetts Savings Bank Life Insurance Department prop- erly for extending this phase of service we submit an act on page 175, which we believe will make it more available to the wage earners desiring it. The advantages of this type of insurance are twofold. It preserves to the individual his present freedom and exercise of resourcefulness, and makes it possible for him to insure voluntarily at a nominal fee. It requires the establishment of no new departments, boards or commissions, but through an efficient existing agency furnishes better opportunities to wage earners for insuring against illness at their option. Before recommending this measure, the Commission con- ferred with the Savings Bank Life Insurance to determine if that department was willing to undertake an extension of the group insurance work already being done, and as evidence of their willingness to do so a part of a letter sent to the Commis- sion is quoted herewith: — The trustees of the General Insurance Guaranty fund are much in- terested in the possibilities for social service work along the lines of vol- untary sickness associations, and appear to be entirely willing to place at the disposal of your Commission the machinery of our Savings Bank Life Insurance organization for the purpose of conducting through that medium an intensive educational campaign among employers and employees for the organization of such associations in industrial plants throughout Massachusetts. 38 SOCIAL INSURANCE. [Jan. VoiiUNTAEY Health Insueance. As a means of relieving the burden which illness often im- poses on those of limited means, the majority of the Com- mission submits recommendations which it believes will result in the extension and more effective administration of existing voluntary agencies in the Commonwealth. It is our opinion that an ultimate solution of the sickness indemnity question may be partially reached at least through the growth and development of voluntary industrial mutual benefit associa- tions now in operation. The form of voluntary insurance engaged in by the Massachusetts Savings Bank Life Insurance, which has for some time been organizing group insurance in industrial plants, presents great possibilities. To equip the Massachusetts Savings Bank Life Insurance Department prop- erly for extending this phase of service we submit an act on page 175, which we believe will make it more available to the wage earners desiring it. The advantages of this type of insurance are twofold. It preserves to the individual his present freedom and exercise of resourcefulness, and makes it possible for him to insure voluntarily at a nominal fee. It requires the establishment of no new departments, boards or commissions, but through ar efficient existing agency furnishes better opportunities to wag< earners for insuring against illness at their option. Before recommending this measure, the Commission con ferred with the Savings Bank Life Insurance to determine that department was willing to undertake an extension of tl group insurance work already being done, and as evidence ' their willingness to do so a part of a letter sent to the Commi sion is quoted herewith: — The trustees of the General Insurance Guaranty fund are much terested in the possibDities for social service work along the lines of i untary sickness associations, and appear to be entirely willing to placf the disposal of your Commission the machinery of our Sa\dngs Bank L... Insurance organization for the purpose of conducting through that medium an mtensiye educational campaign among employers and employees for the organization of such associations in industrial plants throughou Massachusetts. Page Missing in Printing ?6^ ^?+*' offers excellent i their later years at the age of six twenty, at a mc 1918.] SENATE — No. 244. 41 insurance as an alternative. One of the largest mutual benefit associations in the State, numbering probably 15,000 members, is maintained wholly by the employees without any contribu- tion whatever on the part of the corporation; the association is administered exclusively by them, and they adjust the dif- ferent rates of premium and the proportionate variation in the amount of benefits paid. The Commission cannot commend too highly welfare work of this nature. Voluntary Thrift. The inhabitants of Massachusetts have been distinguished for individual characteristics since the early days of the Massa- chusetts Colony. The spirit of the early pioneers, their en- durance and forethought, their independence and thrift, have persisted to this day, and are reflected in their industries. Immigration and the changing character of the population have not diminished these qualities. That the wage earners of the Commonwealth still practice thrift is evident from the report of the Massachusetts Bank Commissioner for the year ending Oct. 31, 1917. Savings bank depositors in that year numbered 2,492,867, with deposits totaling 11,022,354,841.09, or averag- ing something over |400 for each person. A large part of our people are beginning to avail themselves of the opportunity afforded by the 196 savings banks, together with the .co- operative institutions in Massachusetts, for saving at a good rate of interest. The extent to which th.e working people of all classes have invested in Liberty Bonds is further evidence that thrift still exists, and prevails possibly to a greater extent among the citizens of our State than elsewhere. The steady increase in the amount of life insurance taken out by our working people, through the medium of stock and mutual companies, as well as through the State Savings Bank Life Insurance, is encouraging. The opportunity afforded Mas- sachusetts wage earners early in life to purchase, through the Savings Bank Life Insurance, annuities at a small cost offers excellent inducements to all to provide an income for their later years. For example, an annuity of $100 to begin at the age of sixty can be purchased by a person at the age of twenty, at a monthly payment of 11.07, or a weekly payment 42 SOCIAL INSURANCE. [Jan. of 25 cents, the premium increasing proportionately with the amount of the annuity, to a maximum annuity of $800 a year. This form of saving should become more and more popular as time goes on and as people become better informed of its advantages. "Give us higher wages and we won't ask for health insur- ance; we will take care of ourselves," was the solution of the sickness problem advanced by one labor representative. The average of wages has risen in the Commonwealth recently and. to a marked degree. The majority was impressed with the good wages paid in the industrial establishments visited by it and with the statements of clerks and others appearing at evening hearings in some of the textile centers, who freely admitted that compensation in the mills held out far greater attractions than that offered them by the average tradesman. Nevertheless, in these days, when the purchasing power of the dollar is fluctuating and rapidly decreasing to a point never be- fore known in the history of currency, the question of adequate wages seems to be difficult of solution even for the economist. Compulsory insurance has in some countries abroad been termed "compulsory thrift." We believe that the encourage- ment of voluntary thrift is more in keeping with the American policy of freedom for the individual than thrift through com- pulsion. • Health Insurance Abroad. The statement that favorable results have been obtained in European countries where health insurance is established is not borne out by statistics. In Germany, where health insurance was first introduced, the average number of wage earners recorded as ill in 1890 ^ was 36.7 per 100 insured members, and 45.6 in 1913.^ The corresponding figures in Austria were 45.7 in 1890 and 51.8 in 1913.' The average length of sickness for each sick member increased in Germany from 16.2 days in 1890 1 to 20.2 in 1913; = and in Austria from 16.4 in 1890 to 17.4 in 1913.' The average number of working days lost by each insured member on account of illness was 5.9 in Germany in 1885,* when the law had just taken effect, 6.19 in 1890,* 1 Germany Statistischos Jahrbuoh fUr das Deutsche Eeioh, 1892, pp. 197, 198. 2 Monthly Review of the United States Bureau of Labor Statistics, May 1916, p. 77. " Ibid., November, 1916, p. 127. * W. Harbutt Dawson, Social Insurance in Germany, 1883-1911, pp. 91, 94. 1918.] SENATE — No. 244. 43 and 9.19 in 1913.i The Austrian statistics disclose an increase from 7.98 days in 1890 to 9.45 days in 1913.^ In the United States, where compulsory insurance has not yet been adopted, health conditions are still superior to those in Germany and Austria. A comparison of the number of work- ing days lost on account of illness in the United States and these two countries apparently confirms this opinion. In Germany an average of 9.19 days is lost annually by each insured person, despite the fact that compulsory health insur- ance has been in operation in that country for about thirty years.i In Austria this average rises to 9.45 days.^ A survey of health conditions among the wage-earning class in Boston in 1916 indicated an annual loss of 6.5 working days for both sexes,^ a figure somewhat below that prevailing in other parts of the country where similar surveys have been made. It is significant to note, however, that all studies made in this country have shown the number of days lost on account of illness to be well below those quoted for European countries. Relation of Sickness to Poverty. In the discussion on health insurance much has been said of poverty as a consequence of illness and of illness as a con- sequence of poverty. It has always been most difiicult in a consideration of the problem of sickness and poverty to define the exact relationship between them. The Commission of last year devoted considerable space to a study and discussion of this aspect of the question with which we have been much impressed. The present Commission has made some investiga- tions in this direction and concurs with many of the statements in the report of last year. As far as the Commission has been able to discover, living conditions in this Commonwealth are decidedly more favorable than those in foreign countries, par- ticularly in some of the great metropolitan cities where com- pulsory health insurance is already in force. The great contributing causes of poverty in the Common- wealth we find to be tuberculosis, insanity, feeble-mindedness, intemperance, insufficient wages, lack of education, shiftless- 1 Monthly Eeview of the United States Bureau of Labor Statistics, May, 1916, p. 77. 2 Ibid., November, 1916, p. 127. ' A Siclcness Survey of Boston, Mass., 1916, p. 22. 44 SOCIAL INSURANCE. [Jan. ness. In a study of 389 cases of dependency selected from the 3,516 cases to which mother's aid was given by the State Board of Charity, it was found that 49.4 per cent, of the cases was caused by tuberculosis; 27.6 per cent, by insanity; and 23 per cent, by all other diseases. (See diagram, page 85.) In view of the failure of the sanatorium benefits under the health insurance act in Great Britain, it is difiicult for the Commission to feel that any system of health insurance would tend to alleviate or greatly improve the conditions caused by these two first-named diseases. Most of the foreign health insurance systems now in practice make no provisions whatever for chronic ailments, such as- tuberculosis,- insanity, cancer or diseases extending over a period of twenty-six weeks in any given year. The feeble-minded problem can never be solved by any system of compulsory health insurance. In the event of wage earners succumbing to either of these two diseases it is conceivable that a measure of this kind might improve the condition of the members of the families affected to a degree; but an act for this purpose alone is gratuitous, since such con- tingencies are already provided for by other agencies. If health insurance were to become compulsory in this Com- monwealth in accordance with the standard bill, all citizens, or nearly all, now reduced to poverty by the foregoing causes would still be excluded from the group of beneficiaries unless by express provision they were included in the act. Our institutions for the care and treatment of these patients would still have to be maintained. The overseers of the poor and the State Board of Charity, the dispensaries and clinics, would still be performing the work they are now doing at approxi- mately the same expense. The majority seriously doubts whether health insurance would in any great degree lessen poverty, or so much of it, at least, as is due to sickness. Those persons in the Common- wealth whom the standard bill is designed to help are already in a position to avail themselves of medical service, and in- demnify themselves through voluntary insurance, if they so desire, against loss caused by sickness. 1918.] SENATE — No. 244. 45 Sanatorium Benefits. Reference has already been made to a study of a group of 389 of the 3,516 cas'es analyzed, to which mother's aid was furnished through the medium of the State Board of Charity, showing that in 49.4 per cent, of the cases tuberculosis was the cause of incapacity. (See diagram, page 85.) Despite the great improvement in the treatment of this disease in the Com- monwealth, and the substantial reduction in the mortality rate from this cause, those who are most concerned in the effort to eradicate the disease realize, nevertheless, that much remains to be done in order to enable the Commonwealth to cope with it more effectually. At the present time there are being treated in the various sanatoria in the State 6,000 patients in different stages of tuberculosis, besides those who are given care in their homes and elsewhere. Since tuberculosis still constitutes a large percentage of the fatal diseases in the Commonwealth, it presents, as it has for a long time, the most diflScult phase of our health problem. The Commission has had brought to its attention the partial failure of health insurance abroad in so far as the sanatorium benefits are concerned. The sickness insurance system in Great Britain was the subject recently of special study by a commission appointed by Parliament, composed of sixteen members, including among others, several members of Parlia- ment and representatives of labor. A copy of the report made by that commission contains much interesting criticism and comment. A statement in regard to sanatorium benefits we have thought worthy of reprint here, since it indicates, apparently, that the provisions .relating to the treatment of tuberculosis have not had the effect antici- pated by the advocates of the system. The tuberculosis scheme cannot be regarded as a success; and, in all probability, much better results would be obtained were the existing system of overlapping control brought to an end and the whole responsi- bility vested in one public health authority. In regard to the operation of the British act in general, we quote Maj. WilHam A. Brend, M.D., who wrote, in "The 46 SOCIAL INSURANCE. [Jan. Nineteenth Century and After," July, 1917: "The funda- mental fault in the national insurance act, from the point of view of public health, is that it does little or nothing to touch the great environmental causes of disease. It is palliative rather than preventive." The recent tendency towards a system of State medicine in Great Britain may have some significance in this connection as an evidence of growing dis- satisfaction with the plan now in operation. Inasmuch as a great deal of useful machinery has been built up in the Commonwealth for the purpose of treating tuber- culosis, the majority believes that a plan of sickness insurance would incur grave possibilities of disrupting the present con- structive policy of the State with regard to the prevention of that disease. We deem it advisable to recommend that more complete recofds be kept of the causes and nature of all dis- eases treated by physicians in this Commonwealth, and a return of them made to the State Department of Health, in order that any study undertaken in the future on this subject may have these records and concrete facts available as a basis for definite conclusions. Community Health. A phase of health work unique in character, and, so far as the Commission is aware heretofore unknown in the field of medicine, is the community health demonstration experiment undertaken recently in Framingham, Mass., under the super- vision of a committee of the National Association for the Study and Prevention of Tuberculosis. This experiment, financed by one of the large life insurance companies in the country, has already had demonstrable effect, and has attracted the attention of national health authorities. Steps have now been taken to establish similar health centers abroad. The Commission was highly impressed by this experiment, and called into con- ference Dr. D. B. Armstrong, the physician most intimately concerned in the immediate administration of the work, who outlined for the information of the members the purpose of the experiment and the scientific lines upon which his committee was proceeding, together with some of the mbre significant results already obtained. 1918.] SENATE — No. 244. 47 Briefly, the object of the committee in inaugurating the work in Framingham was to make use of agencies and machinery already in existence, and, by popularizing the subject and interesting the public in the project, to enlist their co-operation and insure its success. That this part of the committee's program has been successful is evident from the reports, which show that schools, churches, clubs and factories have taken up the work and are co-operating in every way possible. It was stated by Dr. Armstrong at the conference that one of the primary objects of the association in undertaking the experi- ment was to encourage the community to meet its own obliga- tions. The association in its work at Framingham laid special emphasis on the prevention and treatment of tuberculosis. The education campaign carried on in connection with this health work directed attention to the importance of discovering tuberculosis and other' diseases in their incipient stages, and giving them proper and intelligent treatment. A great number of citizens in the town have voluntarily submitted to physical examination, in order to enable the committee of the associa- tion to carry out one of the chief objects of its health program, namely, pathological survey of a representative number of persons with a continued observation of the group under medical treatment. The examinations have been made by reputable physicians, and their findings have revealed a very large percentage of defects in the health of the community. The following is a paragraph taken from a recent article submitted by Dr. Armstrong to "The Journal of Outdoor Life," which summarizes the main objects of the association: — We hope to discover disease, especially tuberculosis, in its incipiency, with the help of the local physicians, through the special examinations that have been and that are being carried on, and through the special work among infants, in schools, in factories and elsewhere. Adequate treatment facihties, especially for tuberculosis, will be pro- vided as above outlined, wherever possible on a basis of permanency, and in such a way as to require the local community to meet its own logical and natural obligations. Finally, it is hoped that general sanitation, health education and con- tinuous medical supervision will act as effective instruments in the pre- vention of unnecessary disease and defect. Thus far the health demonstration has showa that with sympathetic co- 48 SOCIAL INSURANCE. [Jan. operation from local and outside agencies, the basis for community social control over disease-producing factors can be laid. It is the hope of the committee that further developments of the work will demonstrate that on a community basis disease may be prevented and health created, thereby laying a permanent physical foundation for future social, economic and spiritual evolution. Community health work of the character inaugurated in Framingham cannot fail to commend itself to all who have the conservation of public health at heart. The work at Framing- ham has demonstrated beyond question that a community can independently build up a very efficient health system by proper and sympathetic co-ordination of all its factors. The Extension of Free Clinics. The report submitted by Michael M. Davis, Jr., of the Boston Dispensary, as the result of his study of dispensaries and clinics in the State, reveals the fact that 938,000 visits are paid annually by the people of the Commonwealth to the 52 dispensaries and free clinics in various parts of the State. This indicates that the people are availing themselves to a great extent of this kind of medical service when obtainable, at the present time. The study shows that the city of Boston is far better equipped than any other section of the Commonwealth, having no less than 22 dispensaries and clinics, of which fully a quarter of the population of Boston made some use in the year 1917. The majority of the Commission believes that this type of medical service should be extended and made even more avail- able than is the case at the present time. In our opinion, however, nothing should be done to increase the number of dispensaries unless at the same time all institutions of this class are placed under some State supervision. At present dispensaries are responsible to no public authority, except that in their administration of charitable funds they must report to the State Board of Charity. The State Department of Health should be given authority to license all dispensaries and prescribe general regulations for their management. Such a law would prevent the development of commercial, exploiting institutions, some of which now exist, and would enable a 1918.] SENATE — No. 244. 49 constructive development of medical service to proceed in an orderly way, without, however, hampering local initiative. To assist in the development of dispensaries the majority of the Commission recommends : — 1. Providing diagnostic equipment to suitably established dispensaries or out-patient departments, this form of subsidy being conditioned upon adequate local appropriations for maintenance and the conduct of the dispensary according to an approved standard. 2. Providing for the smaller communities the services of specialists along certain lines (oculists, laryngologists, orthopedists, etc.), visiting the clinics at periodic intervals. 3. Providing visiting nurses doing preventive and educational work, with the dispensaries as central points in each area. An act is submitted. Appendix, page 175, the passage of which it is believed will accomplish in a measure the first of the foregoing recommendations. A majority of the Commis- sion favoi-s the passage of a license law for dispensaries, legis- lation for which we understand is already pending. Cost. Since, owing to the war, abnormal economic conditions now prevail everywhere, a majority of the Commission has felt that in the study of the proposed systems of health insurance par- ticular consideration ought to be given the economic phases of the question. The cost of a scheme of sickness insurance is a matter of vital concern to the State, which becomes a con- tributor, as proposed in the bills brought to the attention of the Commission, though it is not a matter of such great concern in other systems, — the German system, for example, — where the employee bears two-thirds of the cost of insurance and the employer one-third, but where "the government contributes only to the extent of paying certain expenses of supervision." ^ A system of this kind has not yet been advocated by American workmen. From the experience of foreign countries it appears that any effort to calculate accurately the cost of a system of compulsory health insurance in advance of the passage of the act has been Report of the Special CommisBion on Social Insurance, 1917, House No. 1850, page 248. 50 SOCIAL INSURANCE. [Jan. almost futile, since the expense in every instance has proved to be in excess of the highest estimates. The national insurance bill of Great Britain, for example, cost the nation more than 50 per cent, over the amount first computed. In estimating the cost of a system of sickness insurance for Massachusetts we can do no better at present than follow the method of computation employed by the Commission of 1916, on the basis of House No. 1074 and the figures of the total pay roll of wage earners in the Commonwealth in 1915 receiving less than $1,200. Assuming the cost of this insurance to be 4>^ per cent, of the total amount of the earnings of wage workers receiving less than $1,200 annually, — the percentage sub- mitted by an eminent authority, — and allowing for an addition of 10 per cent, to the amount of the pay roll for 1915 referred to above, as the average percentage of the wage increase in the three years intervening, and an addition of 1 per cent, to the number of wage earners who would come under the act, the majority finds that the total cost of such a system of health insurance for the State would be approximately $43,000,- 000 annually. This estimate, though liberal, might very well prove to be, like the appropriation of Great Britain, 50 per cent, below the actual expense of operation. We do not believe that the loss due at present to illness of the wage earner, plus the economic loss due to such illness, will at all approximate this figure, especially when we consider that the cost of caring for wage earners suffering from most of the chronic diseases is not included in the above figures. We find a direct analogy to sickness prevention in fire and accident prevention. Municipal authorities and property owners have reduced the losses to life and property by raising the standards of building construction and otherwise safeguard- ing their interests. Employers of labor have materially reduced the number of accidents to their workmen by the installation of safety devices and appliances. If this conserva- tion of life and property has been effected by voluntary Gie and accident insurance we have a right to expect even greater results under an efficient system of sickness prevention and the extension of the functions of existing voluntary insurance agencies. On page 169 of this report is a diagram referred 1918.] SENATE — No. 244. 51 to before on page 40, showing the results obtained from the introduction of a dispensary in a large manufacturing plant. It is fair to assume that the enormously increased expendi- tures which the taxpayer will have to bear on account of the war will raise the State tax for the current year far in excess of any heretofore levied in the Commonwealth. Since the State debt is already about $88,000,000, which is larger than any other State debt per capita in the union save one (New York), we believe it would be decidedly unwise to recommend legislation involving such a large expenditure without some regard to the cost. It does not follow from this, however, that were the nation not at war we should advise this legislation. Nor do we oppose compulsory health insurance solely on the grounds of its excessive cost; on the contrary, the majority of the Commission feels strongly that the lives and health of our wage earners are of such vital concern to the Commonwealth that any meritorious scheme which has for its primary object the relief of the overburdened members of society, the ameliora- tion of their condition, and the prevention of disease should be given the most serious consideration, investigation and scrutiny. If these desirable conditions seemed likely to be realized by the plan of compulsory health insurance recently proposed in our State we should feel, despite the monetary problem it presented, inclined to commend if not to recommend such legislation. The Standard Bill. In conclusion we have believed it wise to consider here briefly certain provisions of the so-called "model bill," providing for compulsory health insurance, inasmuch as this measure has been presented at three sessions of the General Court in our own State, and bills almost precisely the same have been presented in a great many other States in the country. The act of last year. House No. 1074, was entitled "An act to establish a system of compulsory insurance to furnish benefits for employees in case of death, sickness and accident, not covered by workmen's compensation, and for their de- pendents in case of sickness and accident, and to furnish maternity benefits, and to provide for contributions by em- 52 SOCIAL INSURANCE. [Jan. ployers, employees and the Commonwealth, and to create the Health Insurance Commission." Prevention. The only section in the act referring in any manner to the prevention of disease is section 27 of the bill, which reads as follows : — Funds or societies may, with the consent of the commission, and for purposes approved by the appropriate local or state public health au- thorities, make appropriations for prevention of disease and the education of its employer and employee members in disease prevention and hygiene, and include the amount so appropriated among its expenses of adminis- tration. It will be noted that the provisions of this act are rather loosely drawn, and the question of providing funds to be applied for the prevention of sickness is left entirely optional with the Commission. It will be observed, also, that the matter of providing education in hygiene is apparently a matter of choice with the Health Insurance Commission. Therefore it would seem in the drawing of the act that the question of the prevention of illness has not apparently been given primary consideration. Expense of Bill. As has already been pointed out, the cost of maintaining an act of this kind is a matter of assumption. The bill introduced in the Massachusetts Legislature appears to put no limit on the amount of the contributions, but states that "contributions shall be computed so as to be sufficient for the payment of benefits, the expense of administration of the fund and its reserve, and the maintenance of the guarantee fund." The additional benefits, such as dental service, nursing, etc., would add greatly to the expense. It seems safe to say, as has already been stated in another part of the report, that the cost of administering the act would probably prove far in excess of the estimates already sub- mitted. In the distribution of the cost the framers of the bill have determined on a pro rata contribution of two-fifths by the employee, two-fifths by the employer and one-fifth by 1918.] SENATE — No. 244. 53 the State. It has not been satisfactorily explained just why the employer should bear such a large part of the expense of health insurance, since there are no facts available to prove to what extent industry is responsible for disease. It should be observed here, moreover, that under the German act the employee pays two-thirds of the cost, the employer one-third and the government bears no part of the financial burden. The "model bill" is said closely to simulate the German act in most other respects. Administration. Moreover, there are numerous provisions for the administra- tion of the act which would in effect disorganize our present systems and add materially to the cost. It is provided that five commissioners and a secretary shall be appointed by the Governor and paid substantial salaries. In addition to the commission of administration it provides for a health insurance council of twelve members, an advisory board of eleven mem- bers and a nurses' advisory board of seven members. Au- thority is given for the establishment of so-called local funds and trade funds as carriers for the distribution of the benefits. Section 13 of the act provides that in each district there shall be a panel or local medical committee of not less than seven or more than fifteen members. Their powers are stated and duties enumerated to a certain extent. One of its serious discrepancies, it seems to a majority of the Commission, is the failure to provide for any supervision of the health insurance system by the State. It has been admitted that there is a necessity for supervision over other functions of government, and in view of the fact that the Commonwealth has a very efficient Insurance Department it would seem wise that it should be given a measure of control over any health insurance law proposed. In addition to some of the weaknesses and shortcomings in the bill, which have been pointed out in the foregoing summary, we would call attention to the compulsory features, which are compulsory only in so far as they compel payments under the act. Beneficiaries are not required to report illness, nor are they obliged to accept medical treatment. 54 SOCIAL INSURANCE. [Jan. Insurance for Self-employed Persons. It has been charged, and we believe with warrantable excuse, that the act is unfair to the self-employed person whose earnings do not exceed $100 a month on an average. Although pro- vision is made in the act for him to insure himself voluntarily by contributing a certain amount, he is compelled in addition to pay two-fifths of his employees' contributions. In the case of a small merchant or tailor, for example, employing a few helpers or only one, the situation often arises where the em- ployee's compensation equals and even exceeds that of his ' employer. The imposition of this extra burden on the small employer is an obvious discrimination. To recapitulate, the bill fails in what it seems to the ma- jority of the Commission should be the primary function of any health measure, namely, the prevention of disease. The administrative provisions are drawn loosely, and present great possibilities of political abuse. There is no provision made for proper supervision of the act. A very large- class of our needy citizens would fail to come under the law as drawn. The benefits provided have not been given adequate consideration in connection with the cost. There is grave danger of encour- aging malingering and no adequate means of restricting it. The theory of the distribution of the cost appears to us to have been made without sufficient consideration of the fundamental causes of illness and the extent to which industry is responsible. Indemnification not the Solution. The term ''health insurance" is to a material degree a mis- nomer, since it is concerned primarily with indemnity for wage loss. The real solution of the health question, it seems to us, is not indemnification for wage loss during illness, but preven- tion of illness. Statistics have proved that far from diminish- ing illness, indemnification for wage loss has increased it and encouraged malingering. To cope intelligently with the sick- ness problem, therefore, our energies should be directed to making possible the extension and greater efficacy of our present preventive work. To divide our energies in an attempt to furnish aid to the worker while ill through compulsory 1918.] SENATE — No. 244. 55 insurance benefits must result in a cessation or diminution of our present policy of prevention. Since the maintenance of a high standard of public health through the prevention of illness is more desirable than through the post facto treatment of disease, the majority of the Commission believes that it would be wiser, under the present circumstances, to follow a con- structive policy of preventive medicine than to initiate any scheme of health insurance. The majority earnestly commends to the attention of the Legislature the suggestions as well as the recommendations contained in its conclusions, and for legislation submits in the Appendix, page 175, first, An Act to extend voluntary group insurance; and second. An Act to provide diagnostic equip- ment for clinics and dispensaries and to encourage their extension. Below is a statement of one of the signers of the ma,jority report in which he modifies his position on certain of the fore- going conclusions. HERBERT A. WILSON, CHARLES D. BROWN, FRED P. GREENWOOD, CHARLES B. PROTHINGHAM, BENJAMIN G. COLLINS, CARL C, EMERY, ERNEST A. LAROCQUE, ROBERT M. WASHBURN, EVERETT MORSS, Majority of the Special Commission on Social Insurance. 56 SOCIAL INSURANCE. [Jan. STATEMENT BY ROBERT M. WASHBURN ON HEALTH INSURANCE. For legislation I favor such a preventive measure as so- called free school health, outlined later, and not so-called health insurance. My mind is clear as to the desirability of the former, and the expense is less than that of the latter. My endorsement of the majority report to which reference is herewith made is complete except so far as it may be herein qualified. I do not assimie the responsibility, in these abnormal times, of opposing health insurance. It has behind it inteUigent sponsors and intelligent communities. It has been endorsed by a number of men who enjoy the highest respect politically, professionally and commercially. It is advocated by the Governor of this Commonwealth, whose position in the State as an oiOBcial and whose record as a legislator entitle this question to careful consideration. It is interesting to note that the labor unions favor compul- sory non-contributory health insurance and are opposed to compulsory contributory insurance. I venture respectfully to suggest that in a further consideration of this question the unions listen as openmindedly as possible to the strongest arguments which can be found in favor of solutions of this problem to which they may now feel opposed, in order that their final conclusions may be wise and to their own best advantage. I am inclined to the feeling that there is one argument for compulsory contributory legislation which has not been given due weight. Private mutual benefit associations are very successful, particularly in the large concerns, and with the lowest paid operatives. It must be apparent that the same benefit which these operatives are now receiving, at their own exclusive expense, would be reduced in cost to them were the State and the employer forced substantially to participate under a bill compulsory on all three of the parties. From this I am 1918.] SENATE — No. 244. 57 inclined to think that an employee is better off, financially, under a compulsory contributory bill than as a member of a private benefit association, and without health legislation of any sort, which still, however, leaves open the question, is compulsory thrift American. The most significant part of our hearings to me is that, with some few exceptions, the medical profession, as organized and as individuals, particularly those of age and long experience, upon repeated inquiry, have been unable to make any suggestions for legislation by which the plane of health may be raised or the evils of illness alleviated. And as a corollary to this proposition, in considering the merits of further legislation, it should be borne in mind as vital, its effect upon the efficiency of the profession and its proper monetary returns, and the evils of commercialism in practice. I cannot escape the conclusion that the ideal physi- cian should steer his course between the financial thrift of the business man and the altruism of the clergyman. In the present absence of legislation on health insurance a class in the community continues to bear a burden which is not only great but which it is least able to continue to carry. It is this class which has a right to ask for a greater degree of legislative consideration and loyalty than any other, and the rules, even of logic, a father ought at times to temper in his attitude towards a needy child. The movement in the present Constitutional Convention to enable the Legislature to act upon this problem, without the possibility of its being questioned constitutionally, is much to be commended and will probably succeed. The interest in health insurance in this Commonwealth, perhaps because of present conditions, is not only small but divided as to all- the interested parties. No two stand together, or perhaps can be brought together. The employer opposes all legislation of this sort; the employee favors only a non- contributory bill. It is difficult to determine the attitude of the physicians as a class. There is some support for so-called preventive measures. The Commission of 1916 included able members. Their report showed work and thought and progress. On the other 58 SOCIAL INSURANCE. [Jan. hand, they were together only as they sat together. They were like the fuse bomb, — they were a unity only in their original condition. When they reported, like the report of the bomb, their original elements found diverse final resting places compared to which the report of the present Commission seems to be without a dissenting voice. I submit these two considerations as evidences of a lack of unanimity of sentiment. My attitude should not be construed as hostile to health insurance,, and I do not accept as conclusive the arguments against it. A study should be continued by an open-minded public because of the size of the question, its precedents in use, and its possibility of ultimate adoption. At this time, however, our heads, pur hearts and our money are across the seas. Perhaps because of these conditions alone I fail to find the four elements vital to wise legislation, — unanimity of senti- ment, the public interest properly to consider and to institute it, the public opinion to enforce it and the funds to carry it. For these reasons I do not feel justified in endorsing, at this time of national crisis, such a material step in legislation as health insurance. ROBERT M. WASHBURN. 1918.] SENATE — No. 244. 59 VIEWS OF A MINORITY REGARDING FREE SCHOOL HEALTH. We believe that medicine should, as much as possible, be kept out of politics in its undesirable sense, the test for pro- fessional preferment being merit and a knowledge of medicine, not a familiarity with the voting lists. We believe that such a policy as outlined below will conserve rather than jeopardize this end. To-day, strangely, the only two considerations which generally prevail in the selection by a patient of a medical adviser in general practice are his personality and his reputation in the community. The patient seeks no accurate means of determining whether his knowledge of medicine is great or small. The choice of a specialist is more wisely made, upon the advice of a member of the profession. The recent strong movement in Great Britain towards so- called State medicine, or treatment of all the people at the expense of the public, is a long step in support of the narrower policy herein below suggested by us. We believe that medical diagnosis, advice, medicine and surgery should be even more within the reach of all the people than at present, with less of a coloring of charity, which often humiliates and repels. We believe that legislation should be slow and safe, and that legislation for the young has a preventive strength, for the field while comparatively narrow strikes all the people. After the analogy of free textbooks we believe in further progress toward free health for all school pupils, the end which should be ultimately reached. The present treatment of pupils in this State seems to lack organization, consistency and completeness. It has not gone far enough. Methods vary with the locality, also the number of physicians and nurses per pupil, while all parts of the State could use, it seems, more money. We believe that in developing this work with due regard to the principles of home rule and uniformity, it should be done 60 SOCIAL INSURANCE. [Jan. under the supervision of both the local and State boards of health; and, to eliminate opposition, the operation of the law should be made optional with the parent. However, as to the manner in which this may be worked out, these are but suggestions. We are not concerning ourselves at present with hygienic instruction, and we recognize that educational boards are at present exercising jurisdiction over this subject-matter, and also, to a degree, over what progress has been made towards our proposed end. We believe that the suggestions which we are making are purely health measures. For these reg,sons, and because of the evils of divided control and responsibility, we are of the opinion that, for our purposes; the jurisdiction of the health boards should be exclusive. In order that the start may be safe, and recognizing the undesirability at this time of assuming the care of all troubles, and the difficulty of discrimination, treatment should begin and stop, for the present, at medical diagnosis in all cases, and the medical and surgical care of the eyes, ears, noses, teeth, throats, lungs, posture and nervous systems of the pupils. We recommend legislation which we believe will accomplish this purpose. A bill will be found in the Appendix on page 176. ROBERT M. WASHBURN. EDWARD F. McLaughlin. VINCENT BROGNA. 1918.] SENATE — No. 244. 61 STATEMENT AND SUGGESTIONS OF A MINORITY. The undersigned members of the Commission find them- selves unable to agree with the conclusions of the majority in another part of the report, and are, therefore, submitting the following statement, including their suggestions and recommen- dations. Realizing the provisions of the resolve required us to confine our consideration to the question of insurance as a means of alleviating disease and furnishing medical aid and relief through insurance to wage earners, we have followed the conferences and hearings held by the Commission with a great deal of interest. The studies undertaken at the request of the Com- mission and submitted in another part of the report have also been given serious thought and consideration. While the minority approached the question of health in- surance without prejudice and with a desire properly to inform themselves as to the measure under consideration, nevertheless we felt that a question which had already been given such favorable commendation by the Chief Executive of our State 'in his annual message to the Legislatures for three years had gone beyond a theoretical point and should be accepted as a practical need. The only question, it seemed to us, was the best means of insuring our wage earners and the proper dis- tribution of the cost. With the subject being considered by cbmmissions under legislative authority in about eight States in the country, it appears that health insurance is rapidly being accepted as inevitable, and the question of the day seems to be what is the best and most practicable way of adapting a system of health insurance to American needs. With health insurance in operation in practically all European countries it seems to us only a question of time when it will be introduced in the United States and become as common and universal here as abroad. Health insurance legislation may be halted tempo- rarily by the war, but the ultimate acceptance of it seems to us 62 SOCIAL INSURANCE. [Jan. to be beyond question. Because of the war, industry is being pressed to an extent never before known in our country. Ammunition factories and other concerns producing necessary supplies are running far beyond their usual capacity. A shortage of labor, due in part to the drafting of a grieat body of our young men for the national army and the cessation of immigration, makes it necessary for a great number of workers to labor long hours and under high tension. European coun- tries are awakening to the fact that their workers must be provided for after the war. The American workmen are already asking what the government is going to do for them following the war. Thus it would seem to us that the war should be an added argument for the early enactment of health legislation rather than for delay. The primary consideration, it seems to us, in a democracy to-day is the conservation of its human resources. The wage earners should be shown this primary consideration because the very existence of our government depends upon them. Therefore to the minority it has seemed not a question whether or not the Commonwealth of Massachusetts should accept health insurance as a solution of its sickness problern and its consequences, but how can these resources be best and most expeditiously conserved. Comments on the Majority Report. We believe it our duty, in dissenting from the conclusions of the majority, to point out some of the reasons for our inability to join them in their conclusions. The principle of insurance as a means of assisting our working people better to carry the burden often imposed by illness seems fundamentally sound. In our opinion mutual benefit associations can never adequately fill the needs of the wage earners. The objections to these agencies are many. At the present time they undoubtedly fill a need, and should by all means be continued until supplanted by a more concentrated, efficient and universal system of State health insurance; but there is a great lack of proper supervision in the case of mutual benefit and local organiza- tions. Their failure and insolvency is not infrequent, and 1918.] SENATE — No. 244. 63 the resultant loss to the members is always discouraging to further insuring themselves in similar associations. In the case of the small mutual benefit associations existing in many of the larger industrial plants and commercial establishments there is no provision for their supervision by the State, nor are they responsible to any one but themselves. While in the case of many of the larger fraternal organizations the law prescribes that they shall make annual reports to the Insurance Depart- ment of the State, it is to be observed that only recently one of the largest and supposedly strongest fraternal associations in the State went into the hands of a receiver. Agencies of this character, then, it would seem, lack the proper regulation, supervision and control by the State. The employees in many cases pay their premiums, but the benefits they receive in the case of illness are so small and cover such a brief period that very little advantage, if any, is derived by the members. We take issue with the majority in their statement that any system of health insurance must result in reducing or discourag- ing present welfare work by industrial plants. All welfare measures, in our opinion, including preventive measures and safety appliances, are introduced primarily for economic reasons. The employers in many cases have freely admitted that welfare work of this order has been inaugurated for the express purpose of retaining their workers, and encouraging them to do better work and put forth a greater effort for the interest of their employer. The introduction in many cases of safety appliances is obviously not always for the purpose of directly benefiting the workers, but, on the contrary, to reduce the employers' liability and cost of insurance. We submit if welfare work of this nature has proved to be of such eco- nomic advantage to industry, would any system of State health insurance seriously interfere with or discourage in any manner employers from continuing the work. We quote from a part of the conclusions of the majority: "Corporations- are agreed that the results of this phase of wel- fare work more than compensate for the effort expended and the expense involved." This being the case it is difficult to understand how State health insurance could in any way diminish welfare activities of this kind. 64 SOCIAL INSURANCE. [Jan. The chief opposition appears to come from the private insurance companies doing business in Massachusetts. They admit that they oppose health insurance for selfish motives alone. We quote here again a part of the testimony submitted by one prominent attorney representing an insurance company doing disability business in Massachusetts, and given more at length in another part of this report: — Health insurance will result in excluding from the field of insurance a great many companies the major part of whose business is writing health and disability iasurance. It arbitrarily forbids private citizens the right to compete with the State for business. If the State is to be allowed to take up the transaction of business at all, then in justice to its own citizens it should enter the field in competition with private interests, be subject to the same business hazards and liabilities, and forced to make good in a fair, open, honorable race of merit. The first duty of any State is to care for its citizens and care for them properly, and we cannot emphasize too strongly what we have already stated with regard to the importance of con- serving the lives and health of the great army of our workers. The health and happiness of these people is of far more vital concern than the personal or private interest of a person or corporation. Though we have no quarrel with the great num- ber of insurance concerns engaged in legitimate business within our State, and thoroughly believe that they are filling a very necessary function at the present time, nevertheless, when any social measure is proposed such as health insurance, which has for its chief object the benefit and relief of our wage earners, we maintain that private interests of insurance companies should always be given secondary consideration. It seems to us little less than ironical for the paid attorneys of insurance companies to come before this Commission with the interesting suggestion that if the Commonwealth engages in the insurance business at all it do so "subject to the same hazards and liabilities" to which their companies are exposed. For the State to undertake a system of insurance on this basis, namely, as a competitor of private corporations, would indeed be a most extraordinary proceeding. One of the chief objects of a State system of health insiurance is to furnish relief to the 1918.] SENATE — No. 244. 65 citizen workers from the excessive charges, exploitation and profiteering practiced by insurance corporations in the past. The mismanagement of these concerns for some years, with their obvious disregard of the publ|ic's welfare, seems to be reflected in some measure by the statement quoted above. The public welfare of our workers cannot for an instant be subordinated to the selfish interests of insurance corporations. It is maintained by the majority in its report that indemnifi- cation for wages lost during illness does not prevent illness. We cannot agree with the other members in this statement, for it seems to us that, on the other hand, reimbursement for wages lost does result in preventing illness or the prolongation of it. It relieves the sick wage earner and his family of the distress incidental to loss of wages and deprivation of the necessities of life; it insures the wage earner against a too early return to work in such a weakened condition that he would be more easily susceptible to disease; and it practically assures to that family the nourishment necessary to their development to stronger womanhood and manhood that they are unable to obtain under the present conditions. The majority of the Commission in its report points out the significance of the fact that the physicians ask for no legislation, and that their' position has been one of opposition to health insurance. The minority believes that the medical profession in opposing the specific health insurance measure proposed recently does so in good faith. The sections of the act relative to the medical administration providing for impaneling the doctors and limiting their activities present grave dangers. We believe that in working out any proper health insurance scheme such latitude could be allowed the physician that his present activities would not be restricted, and the high stand- ards of the profession would be protected and encouraged. There should also be preserved to the wage earner his present free choice of a physician. The study of a selected group to which the State Board of Charity has furnished assistance in the shape of the so-called mother's aid has revealed a great many interesting facts rela- tive to dependency. We believe, however, that the 3,516 cases studied are not truly representative, nor do they disprove the 66 SOCIAL INSURANCE. [Jan. fact that sickness is in most instances the cause of poverty, inasmuch as these cases of dependency were caused through the decease of the father and wage earner, his incapacity or some other irresponsibility. The conclusions of the majority, based upon these cases, are clearly refuted by a consideration of 3,589 cases aided by the Associated Charities of Boston for the year 1917, which reveals the significant fact that in 56 per cent, of the cases aided the families became dependent because of the illness of the bread- winner; only 17 per cent, of the cases assisted was due to dependency because of unemployment; old age was found to be the cause of dependency in no less than 15 per cent, of these cases; and 3 per cent, was due to industrial accidents. This group of families, unselected as it is, presents the condition of a great many families in a large metropolitan city, and for this reason, in our opinion, is more representative of the wage workers than the cases selected from the State Board of Charity. The wages paid in the industries of the Commonwealth under the present unusual conditions may seem high com- pared with those formerly in effect, but a careful comparison with the corresponding advance in the cost of living indicates that wages are still below the ratio existing previous to the war. We contend that the pay of most of the employees is still insufficient to permit them to provide themselves with medical and sickness insurance. A comparison of the health conditions of this country and Germany, indicating, according to the report of the majority, a much higher standard of health with less days of illness here than in the German Empire, where health insurance has been in operation for some time, is to us a manifestly unfair com- parison, since the living conditions there are so inferior to those of this country. The density of the population in Germany has brought about a serious situation so far as housing con- ditions are concerned, and all health authorities are free to admit that a condensation of population results usually in a higher sickness hazard. It was brought to our attention at one of the hearings of the Commission that 55 per cent, of the families in the city of Berlin are living in one room. On the 1918.] SENATE — No. 244. 67 other hand,. we are able to point out the very favorable advan- tage of American wage earners, with an average of four rooms to each family. This, it seems to us, should be taken into consideration when comparing the health conditions of our own country to any of those abroad. The high standard of American living should not be lost sight of in this connection. Because of these favorable living conditions we have a right to expect a superior standard of health, and in our opinion this is a further argument in favor of health insurance. Perhaps nothing is more misleading to the ordinary layman, considering the aspects of health insurance, than the high cost pointed out so frequently by its opponents. The majority of the Commission in its conclusions has attempted to calculate the cost of a system of compulsory health insurance in Massachusetts. Aside from the expense of administering an act, a system of health insurance would not in our judgment add greatly to the expense of caring for the wage earners. The total economic loss of wages due to illness in the State has been estimated to be $38,000,000 annually, and this figure, in addition to the estimated amount of over $12,000,000 paid annually by the several relief agencies, public and private, should be given consideration whenever the cost of a system of sickness insurance is in question. Under any system of health insurance a great many items of expense incidental to the carrying on of private insurance would be eliminated. There would be, for example, no com- missions, rentals, profits and other overhead charges such as are present in commercial insurance at the present time. Any calculation of the cost of a system of health insurance prior to the drafting of a specific measure on which to base it is an assumption at best. It is interesting to note that the majority, in their anxiety to justify their position in opposing this humane, progressive, social necessity, and in order that they might have something of a substantial character in their report, have recommended the expenditure of the insignificant sum of $10,000 to care for the numerous sick in the Commonwealth who are unable to pay for necessary medical aid. The minority admits that limited benefits result from properly equipped and conducted 68 SOCIAL INSURANCE. [Jan. dispensaries, but realizes the inadequacy and futility of the method suggested by the majority, and believes that the act submitted by the majority is in part a violation of the Massa- chusetts Constitution, Article of Amendment XLVI., ratified and adopted Nov. 6, 1917. Recommendations. Six months is altogether too short a space of time in which to properly investigate and deal with a question of such mag- nitude as health insurance. The problem is so much broader in its scope, and presents so many more ramifications than did workmen's compensation when that measure was first proposed, that it will, in our opinion, require further study and considera- tion before the adoption of any concrete bill. In the very limited time, however, which the Commission has had to consider the question, the minority feels that sufiicient evidence and proof have been presented to show the vital need of sickness insurance as a means of relief to the over- burdened wage earners in the Commonwealth. While the minority refrains at this time from submitting a bill to establish health insurance, because we have realized some of the difficul- ties involved in enacting a measure of such, great importance, we are thoroughly convinced, however, that a system of non- contributory health insurance is the only solution of the prob- lem of sickness and its contingencies. The principle of non- contributory health insurance appeals to us as being by far the most eminently fair and correct means of solving the question. Any system of sickness indemnity to which the employee is required to contribute to the cost seems to us inequitable, for the total cost in any case must eventually fall upon the working class in the form of higher rents, taxes and other necessary living expenses. A non-contributory plan of insurance com- mends itself then, first, because it is more just to the wage workers, who constitute a majority of the inhabitants of the State; and secondly, because it is comparatively more simple of administration than a complicated contributory form of insurance by "which the State, employer and employee are severally asked to carry the burden. 1918.] SENATE — No. 244. 69 Not only do the figures which the minority has obtained from the Associated Charities support our contention that sickness is a very large factor in the cause of poverty, but a knowledge of the actual conditions existing among the wage earners, acquired from personal contact and association with them, further confirms us in our conviction. In order to deal intelligently and comprehensively with so momentous a question as a State system of health insurance, it should be given adequate and scientific study such as only a permanent commission of paid experts could devote to it. In the case of workmen's compensation no satisfactory solution of the question was found until it was dealt with by a Com- mission composed of social students, economists and labor men. The question of industrial accident compensation presented fewer complexities than that of wage indemnity for illness because of the very nature of the insurance, for it covered a much smaller field and included a far less number than sick- ness insurance, where there is bound to be, by the very nature of the disability, a far greater number of beneficiaries. The minority is, therefore, submitting a bill, Appendix H, providing for the appointment by the Governor of a com- mission of five persons, one of whom shall be a representative of labor, for a period of two years, in which to investigate the question of State health insurance as a means of alleviating conditions among the working people due to sickness and its consequences. The proposed resolve creating the commission provides for a proper and complete study of the conditions and causes leading up to sickness, and for gathering the nec- essary data and knowledge upon which to base intelligent legislative action. Provision is made for studying foreign systems of health insurance, and also for conferring with other State committees and commissions in this country which may be considering the sickness insurance question, in order to cope better and more effectually with the question, and also with a view possibly of drafting legislation which in its more important features, at least, shall be uniform with that adopted in other States. An initial appropriation of $25,000 is provided, and there is laid upon the commission the duty of reporting its recommendations and legislation in January, 1920. 70 SOCIAL INSURANCE. [Jan. 1918. Occupational Diseases. We further feel that the necessity for health and invalidity insurance has increased, since several cases of incapacity arising out of and in the course of employment, which had been generally assumed to have been covered by the Workmen's Compensation Act, are not now covered according to the latest construction by the Massachusetts Supreme Court. In several early decisions the court laid down the following rule: any injury or damage or harm or disease which arises out of and in the course of employment, which causes incapacity for work and thereby impairs the ability for earning wages, was within the act. (Hurle's Case, 217 Mass. 223; Johnson's Case, 217 Mass. 388; Doherty's Case, 222 Mass. 98.) Last summer the court said:^ — A disease of body or mind which, arises in the course of employment with nothing more is not within the act. . . . The doctrine has not been established in Massachusetts that every disease caught by an employee in the course of his employment is a personal injury under the Workmen's Compensation Act. (Frank Maggelet's Case, 228 Mass. 57.) The effect of the last decision is that some occupational diseases are not covered by our act. Therefore, to carry out the original intention of the act as understood by both labor and industry, and to more clearly define the meaning of per- sonal injury, and to more adequately compensate the numerous wage earners for loss suffered through incapacity arising out of and in the course of employment, we recommend the appended bill. EDWARD F. McLaughlin. VINCENT BROGNA. APPENDICES. Appendix A. REPORT OF A SPECIAL INQUIRY RELATIVE TO DEPENDENT FAMILIES IN MASSACHUSETTS EEOEIVING MOTHERS' AID. Prbpaked under the Direction op the Massachusetts Bureau OF Statistics. CONTENTS TO APPENDIX A. I. Nature and Scope of the Inquiry, . II. Summary of Data with Reference to Dependency, 1. Representation by Localities (Table 1) 2. Nativity of the Father (Table 2), . 3. Causes of Dependency, (a) Death of Father (Table 3), . (6) Incapacity of Father (Table 3), (c) Irresponsibility of Father (Table 3), . (d) Alcoholism (Table 4), . .... 4. Age of Father and Dependency (Table 5) , 5. Occupation of Father and Dependency (Table 6), . 6. Weekly Wages of Father and Dependency (Table 7), 7. Amount of Aid received by Families (Table 8) , 8. Number of Children in Family (Tables 9 and 10), . III. Summary of Data with Reference to Insurance, 1. Disposition to insure (Table 11), ..... 2. Insurance on Life of Father, . . . . (a) Amounts of Insurance (Tables 12 and 13), (6) Character of Insurance (Table 14) , (c) Lapse of Time to Dependency (Table 15), (d) Purposes for which expended (Table 16) , (e). Occupations of Insured Fathers (Table 17), . (/) Weekly Wages and Amounts of Insurance (Table 18), 3. Insurance of Members of Family, ..... (o) Number of Members Insured (Table 19), (b) Character of Insurance (Table 20), (c) Cost of Insurance and Weekly Income of Family (Table 21) Appendix. — Detailed Statistical Tables, A to Y, PAGE 77 79 79 81 83 84 86 86 86 87 88 92 93 94 96 96 97 97 99 100 103 105 107 110 110 111 112 115 Appendix A. REPORT OF A SPECIAL INQUIRY RELATIVE TO DEPEND- ENT FAMILIES IN MASSACHUSETTS RECEIVING MOTHERS' AID, 1913-17.- I. Nattjee and Scope of the Inquiry. The Special Commission on Social Insurance, in accordance with a provision of the resolve (chapter 130, Resolves of 1917) authorizing its appointment, secured the co-operation of the State Board of Charity and the Massachusetts Bureau of Sta- tistics in the making of a special inquiry into the nature and causes of dependency in the Commonwealth of dependent fami- lies which received mothers' aid during the period 1913 to 1917. The data on which the inquiry was based were obtained from the records of the State Board of Charity, and the tabulations were made and this report was prepared under the direction of the Massachusetts Bureau of Statistics, the expense of the clerical work having been largely met out of the appropriation for the Special Commission on Social Insurance. In making this inquiry particular attention has been given to those facts with reference to dependency which have a direct bearing upon the subject of health insurance. While the con- clusions drawn from a study of this somewhat limited number of cases may not, necessarily, be true of the entire number of dependent families in Massachusetts, nevertheless the data herein presented will, within certain limitations, prove worthy of careful study in connection with the consideration of any proposed system .of health insurance. For the purpose of describing the conditions governing the granting of mothers' aid, and the methods by which the records used as the basis of this inquiry were obtained, the principal provisions of the act (chp-pter 763, Acts of 1913), in accordance with which the payment of mothers' aid is authorized by the State Board of Charity, are here briefly summarized. Overseers of the poor in the several cities and towns are re- 78 SOCIAL INSURANCE. [Jan. quired to aid all mothers with dependent children under fourteen years of age, if such mothers are fit to rear their children, and the aid furnished must be sufficient to enable the mothers to care for their children properly in their own homes. The act applies to all mothers and their dependent children, whether or not they or any of them may have a settlement in the Com- monwealth, who shall have resided in the Commonwealth not less than three years. No person may acquire a settlement or be in process of acquiring a settlement while receiving such aid. The overseers of the poor, prior to granting such aid, are required to make careful inquiries as to . the resources of each family seeking aid and the ability of any of its members to work or otherwise contribute to its support, and at least once in every three months the overseers, either by one of their own number, or by their duly appointed agent, are required to visit each mother and her dependent children who are being aided by the overseers. After each visit they must make and keep on file as a part of their official records a detailed statement as to the condition of the home and family and all other data which may assist in determining the wisdom of the measures taken and the advisability of their continuance; and at least once in each year they are required to reconsider the case of each mother with dependent children with whom they are dealing, and to enter their determination with the reason therefor on their ofiicial records. The State Board of Charity is charged with the supervision of this work of the overseers, and may visit and inspect any or all families aided under this act, and is authorized to consult any records and other data kept by the overseers of the poor or their representatives relating to such aid. The act further provides that the city or town dispensing mothers' aid shall be reimbursed by the Commonwealth to the extent of one-third of the amount of aid given, if the mother has a settlement in any city or town in Massachusetts; if the mother has no settlement, then the whole amount shall be reim- bursed by the Commonwealth. If she has a lawful settlement in a city or town other than the one in which she resides, two- thirds of the amount of aid granted may be recovered by the town granting it from the city or town of lawful settlement. Of the 6,594 notices of mothers' aid on file in the office of the State Board of Charity, 3,516 cases, covering a period of four years ending Aug. 31, 1917, have been considered for purposes 1918.] SENATE — No. 244. 79 of this report. The eases omitted were principally those reported during the first year of the operation of the act, when the records for the individual cases were not sufficiently complete to justify their use in connection with this inquiry. In general, however, it may be said that, because of the obligation resting upon the overseers to file full and accurate reports relative to families aided, and in view of the careful supervision of the work of the overseers and the independent investigation of cases by the State Board of Charity, the records on which this inquiry are based furnish an exceptionally trustworthy fund of data for statistical analysis. For purposes of analysis, summary tables have been prepared showing the more important data with reference to each of the three principal groups of dependent families, namely, (1) those whose fathers were deceased; (2) those whose fathers were in- capacitated; and (3) those whose fathers were irresponsible. These summary tables, having Arabic numbers, have been inserted in appropriate places in the text of this report, while the detailed tables (numbered A to Y, respectively) form an appendix to this report. In the detailed tables one phase of the investigation has been correlated with another, as, for example (in Table A), the number of deceased fathers whose families were dependent have been classified by causes of death and occupations. The detailed tables could not, within the limita- tions of space here afforded, be fully discussed, but the more significant facts brought out by this investigation have been discussed in subsequent paragraphs. Three charts, illustrative of the more important results of this inquiry, have been inserted in appropriate places in the text and are there discussed. II. Summary of Data with Refekence to Dependency. 1. Representation by Localities. The largest numbers of dependent families naturally were found in the principal cities. Boston led with 1,221 cases, or 34.7 per cent, of the 3,516 cases covered by this inquiry, followed by Worcester, with 152 cases, or 4.3 per cent.; New Bedford, with 146 cases, or 4.1 per cent.; and Cambridge, with 135 cases, or 3.8 per cent. In no other city or town in the State did the number of cases during the period under consideration exceed 100. Assuming that, normally, the numbers of cases in the 80 SOCIAL INSURANCE. [Jan. several cities and towns would vary according to the size of the population of the respective cities and towns, it was found that the number of cases in Boston, constituting 34.7 per cent, of the total number of cases, was disproportionately large, in view of the fact that the population of Boston (in 1915) constituted only 20.2 per cent, of the total population of the State. Like- wise, in Cambridge, the number appeared to be somewhat dis- proportionately large. Of the 3,516 cases, 2,645, or 75.2 per cent., were confined to 22 cities. All of the 38 cities and 267 of the 316 towns in the State were represented in these returns. The following table shows for the principal localities repre- sented the number of dependent families classified in three principal groups, namely, families whose dependency was the result of (1) the death of the father, (2) incapacity of the father and (3) irresponsibility of the father : — Table 1. — Number of Dependent Families considered in the Investigation classified by Cawes of Dependency and Locality where aided. CAtJSES OP DEPElfDENCY. City or Town whebe aided. Death of Father. Incapacity of Father. Irre- sponsibility of Father. Total. Boston, . ... 888 172 161 1,221 Brockton, . 37 8 6 51 Cambridge, 102 20 13 135 ChelBea, 67 3 ^~ 77 Everett, . 36 12 13 61 Fall Eiver, 57 8 8 73 Gloucester, 25 3 3 31 Haverhill, 22 3 25 Holyoke, . 45 2 12 59 Lawrence, 50 2 7 59 Lowell, 78 7 9 94 Lynn, 42 3 12 67 Maiden, . 59 10 74 New Bedford, 115 24 146 Newton, . 42 5 51 Quinoy, 28 4 36 Salem, 28 10 39 1918.] SENATE — No. 244. 81: Table 1. — Number of Dependent Families considered in the Investigation, classified by Causes of Dependency and Locality where aided — Con. Causes of Dependency. City or Town where aided. Death of Father. Incapacity of Father. Irre- sponsibility of Father. Total. Somerville, . ... Springfield, . ... Taunton, . . Waltham, Worcester, Other cities and towns, Not stated, ... 42 69 21 31 125 637 13 4 9 2 5 10 96 2 10 14 1 6 17 121 2 56 82 24 42 152 854 _ 17 Totals, 2,649 389 478 3,516 Examination of the foregoing table shows that the dependency of 75.3 per cent, of the 3,516 families considered was due to the death of the father, of 11.1 per cent, to the incapacity of the father, and of 13.6 per cent, to the irresponsibility of the father. The corresponding percentages for the several localities did not, in most instances, vary greatly from these percentages. 2. Nativity of the Father. The number of families whose fathers were native born was 1,442, or 43.1 per cent, of the total number of families (3,347) the nativity of whose fathers was stated. Of these 1,442 native- born fathers, 1,083, or 32.4 per cent, of the total number of fathers whose nativity was known, were born in Massachusetts, and 359, or 10.7 per cent, of the total number, were born else- where in the United States. The number of families whose fathers were foreign born was 1,905, or 56.9 per cent, of the total number of known nativity. Of the foreign-born fathers, 613, or 18.3 per cent, of the total number (native and foreign), were born in Ireland; 431, or 12.9 per cent., in the Canadian provinces (including Newfoundland); 219, or 6.5 per cent., in Russia; 165, or 4.9 per cent., in Italy; and 133, or 4 per cent., were born in England. In the following table the facts with reference to nativity are shown in somewhat further detail, classified by the three princi- 82 SOCIAL INSURANCE. [Jan. pal causes of dependency, namely, death of the father, incapacity of the father and. irresponsibility of the father. It will be ob- served that for each of these three principal groups of cases the proportion of native to foreign-born fathers was practically uniform. Table 2. — Number of Dependent Families considered in the Investigation, classified by Causes of Dependency and Nativity of Father. Nativitt of Fathebb. Causes of Dependency. Death of Father. Incapacity of Father. Irre- _ sponsibility of Father. Total. Native Born. Massachusetts, Other United States, Foreign Born. Ireland, .... Russia, .... Italy, >•■ Canada New Brunswick, Nova Scotia, . Newfoundland, Prince Edward Island, . England Scotland, .... Germany, Sweden, .... All other countries, . Not stated, Totals, 1,06S 809" >256 i.ies 496 144 134 141 43 64 27 28 105 33 25 55 160 129 US 126 32 Sli 58 39 20 19 5 14 7 5 11 3 3 5 25 17 M9 148 71 sse 59 36 11 45 4 18 4 7 17 3 2 8 22 23 1.UB 1,083 359 1,905 613 219 165 205 52 96 38 40 133 39 30 68 207 169 2,649 389 478 3,516 On comparison of the data with reference to fathers of the dependent families with corresponding data for the general population, it was found that in the case of the fathers of de- pendent families 56.9 per cent, were foreign born, whereas of the general population the foreign-born (in 1915) constituted only 31.2 per cent, of the total population. It therefore appears that for the families covered by this inquiry the percentage of families whose fathers were foreign born was significantly high. 1918.] SENATE — No. 244. 83 S. Causes of Dependency. As the father is ordinarily the chief wage-earning niember of the family, it was found advisable in tabulating the data, both with reference to dependency and insurance, to classify the de- pendent families into three principal groups, namely, those whose dependency was due (1) to the decease of the father, (2) to the incapacity of the father, and (3) to the irresponsibility of the father, and in nearly all of the tabulations this plan of grouping the families has been followed. Chart 1, appearing on page 85, was prepared for the purpose of showing graphically the relative importance of the several causes of dependency. The first circle illustrates the fact that the dependency of three-fourths of the families covered by this inquiry was due to the death of the father, and of only one- fourth to the incapacity or irresponsibility of the father. The other three circles show, respectively, the relative importance (1) of the causes of death of the father, (2) the causes of in- capacity of the father, and (3) the nature of the irresponsibility of the father. It will be observed that tuberculosis was the predominant cause both of death and incapacity of the fathers, that insanity was the cause of incapacity of more than one- fourth of the incapacitated fathers, and that of the irresponsible fathers a very large percentage deserted their families. In the following table the families are classified with refer- ence to the specific causes of the death or incapacity of the father or the nature of his irresponsibility: — Table 3. — Number of Fathers whose Families became Dependent, classified by Causes of Death or Incapacity and Nature of Irresponsibility of Fathers. Cause of Death or Incapacity AND Nature of iBBESPONSEBrLITT OP FATHERS. Deceased Fathers. Inca- pacitated Fathers. Irre- sponsible Fathers. Total. Tuberculosis PneumoDia, . . ... Accident, ... ... Heart trouble, .... Insanity, . . ... 673' 332 284 s 212 46 191 2 13 107 - 864 332 286 225 153 ' 1 * Of this number, 58 were cases in which tuberculosis was a contributory cause. * Of this number, 108 were definitely known to have been cases of industrial accident. 84 SOCIAL INSURANCE. [Jan. Table 3. — Number of Fathers whose Families became Dependent, classified by Causes of Death or Incapacity and Nature of Irresponsibility of Fathers — Con. Cause of Death or Inoapaoitt AND Nature op Ihhesponsibiutt of Fathers. Deceased Fathers. Inca- pacitated Fathers. Irre- sponsible Fathers. Total. Kidney trouble, 127 5 132 Apoplexy, etc., 103 21 124 Cancer, . . . . 102 4 106 Alimentary system, diseases of. 84 6 89 Typhoid fever. 71 71 Complication of diseases, . 62 62 Suicide, . . 48 - 48 Blood poisoning, . . . . 40 40 Appendicitis, 37 37 Respiratory system, diseases of (n.e.s.), . 28 28 Murdered, 12 12 Blindness, _ 6 6 Crippled, ... 6 6 Deserted, 406 406 Divorced, . . . 18 18 Separated, 11 11 Imprisoned, 43 43 Other causes, 164 27 191 Not stated. 224 2 226' Totals, 2,649 389 478 3,516 (a) Death of Father. — Of the 3,516 families considered in this investigation, 2,649, or 75.3 per cent., became dependent as a result of the death of the father. Tuberculosis was the sole or contributing cause of death of 673, or 27.8 per cent, of the 2,425 fathers, the cause of whose death was known. Next to tubercu- losis as the cause of death was pneumonia, 332, or 13.7 per cent., of the deceased fathers having died of this disease. Cor- responding numbers and percentages for other principal causes of death were: accident, 284, or 11.7 per cent, (of which number 108 were definitely known to have been cases of industrial accident); heart trouble, 212, or 8.7 per cent.; kidney trouble, 127, or 5.2 per cent.; apoplexy, 103, or 4.2 per cent.; and cancer, 102, or 4.2 per cent. 1918.] SENATE — No. 244. 85 CHART 1. CAUSES OF DEPENDENCY BASED ON A STUDY OF RECORDS OF THE STATE BOARD OF CHARITY COVERINO 35]G FAMILIES WHO RECEIVED "MOTHER'S AID" DURING THE PERIOD SEPTEMBER l,ISI3 TO SEPTEMBER 1,13]?, ALL CAUSES (based oh a total of 35)e CASES — -CAUSES KKOWN) CAUSES OF DEATH (based on a total of 2425 CASES — CAUSES KNOWn) CAUSES OF INCAPACITY (based ok A TOTAL OF 889 CASES — CAUSES KMOWN.] NATURE OF IRRESPONSIBILITY (based on a total of 47a CASES— CAUSES KNOWN) 86 SOCIAL INSURANCE. [Jan. (6) Incapacity of Father. — The number of families which became dependent because of the incapacity of the father was only 389, or 11.1 per cent, of the total number of families covered by these returns. This representation of families with inca- pacitated fathers was unquestionably small, but it may be ac- counted for in large measure by the fact that the State Board of Charity has definitely adopted the policy of declining to authorize the granting of aid to mothers with dependent children unless it should appear probable that need of aid in accordance with the provisions of law would continue for more than one year. Accordingly, the causes of incapacity as shown in the foregoing table are those which result in prolonged incapacity. For this group of cases, as was also true of the deceased fathers, tubercu- losis was the principal cause of incapacity, 191, or 49.4 per cent., of the fathers having become incapacitated because of this disease, while insanity was the next predominating cause, 107, or 27.6 per cent., of the fathers in this group having been re- ported as insane. No large numbers were reported as inca- pacitated for any other single cause. (c) Irresponsibility of Father. — In addition to the families which became dependent because of the death or incapacity of the father, 478, or 13.6 per cent, of the families, became de- pendent as a result of what, for present convenience, has been termed "irresponsibility of the father," signifying that the father, through fault of his own, was depriving the family of all or a greater portion of his income. Of the 478 irresponsible fathers, 406, or 84.9 per cent., deserted their families; 43, or 9 per cent., were imprisoned; and 29, or 6.1 per cent., were either separated or divorced from their wives. (d) Alcoholism. ■ — Because of the lack of thoroughly reliable information on this subject it was impossible to determine the extent to which the use of alcohol by the father was the cause of dependency of his family. There were very few cases in which the use of alcohol was the sole cause of the father's death, inca- pacity or irresponsibility, but the number of cases in which it was at least a contributing cause was 497, or 14.1 per cent, of the total number of cases investigated. 1918; SENATE — No. 244. 87 Table 4. — Number of Fathers whose Families were Dependent, classified by Causes of Dependency of Families, showing Numbers and Per- centages of Fathers addicted to the Use of Alcohol. Causes of Dependency op Families. Total Number of Fathers. Number of Alcoholic Fathers. Percent- age of Total in Group. Death of father Incapacity of father, . . , . Irresponsibility of father, 2,649 389 478 275 26 196 10.4 6.7. 41,0 Totals, r— ■ 3,516 497 14.1 With respect to the several groups of families, it was found that 10.4 per cent, of the deceased fathers, 6.7 per cent, of the incapacitated fathers, and 41 per cent, of the irresponsible fathers were addicted to the use of alcohol. This wide variation in the percentages for the three groups of cases leads one to conclude that inasmuch as the reports with reference to the use of alcohol by the father were made in most instances by the wife, there may have been some reluctance to tell the actual facts with reference to the husband who had died or was incapacitated; while with reference to a husband who had deserted his family, or who was imprisoned, separated or divorced, the wife would not hesitate to tell the facts in the case. A further analysis of the data shows that of the 406 fathers who deserted, 170, or 41.9 per cent., were reported as intemperate; of the 43 imprisoned fathers, 14, or 32.6 per cent., and of the 29 divorced or separated fathers, 12, or 41.4 per cent., were said to be intemperate. 4. Age of Father and Dependency. The provisions of the act governing the payment of aid to mothers with dependent children operates to select families the ages of whose fathers range principally between 25 and 50 years, for the reason that in comparatively few instances do fathers under 25 years of age have more than one or two children, and these the young wife, in many cases, is able to support when the wages of the father are cut off; while fathers who are 50 years of age or over seldom have more than one or two children under the age of 14 years, which children, in accordance with the provisions of the act, might be deemed dependent. Further- SOCIAL INSURANCE. [Jan. more, in the case of dependent families whose fathers are over 50 years of age children 14 years of age or over ordinarily be- come contributing members of the family. The distribution of fathers according to age groups is shown in the following table: — Table 5. — Number of Fathers whose Families were Dependent, classified by Age Groups. Age Ghoups. Deceased Fathers. Inca- pacitated Fathers. Irre- sponsible Fathers. Total. Under 25 years, 25-29 years, . ... 30-34 years, 35-39 years, . . . . 40-44 years, 45-49 years, . ... 50-54 years, 55-59 years, . . . . 60-64 years, 65 years and over, .... Not stated, . . . . . 50 251 546 619 543 315 130 61 30 14 90 31 60 102 97 47 21 8 4 4 15 6 37 76 140 102 65 23 8 1 2 18 56 319 682 861 742 427 174 77 35 20 123 Totals 2,649 389 478 3,516 The age group 35 to 39 years included the largest number of fathers, 861, or 25.3 per cent, of those whose ages were stated (3,393), being in this group. The next largest number was 742, or 21.9 per cent, of the total, in the age group 40 to 44 years, followed by 682, or 20.1 per cent., in the age group 30 to 34; 427, or 12.6 per cent., in the age group 45 to 49; and 319, or 9.4 per cent., in the age group 25 to 29. The same order of numbers likewise held in the case of incapacitated and of irre- sponsible fathers, and also in the case of the deceased fathers, except that the number in the age group 30 to 34 exceeded slightly the number in the age group 40 to 44. 5. Occupation of Father and Dependency. Information with reference to the occupations followed by 3,297 of the fathers of dependent families was obtained, and the facts with reference to the pi;incipal occupations are summarized in the following table: — 1918. SENATE — No. 244. 89 Table 6. — Number of Fathers whose Families became Dependent, classified by Occupations of Fathers. OoOirPATIONS OF Fathebs. Deceased Fathers. Inca- pacitated Fathers. Irre- ■ sponsible Fathers. Total. Bilkers, 13 1 4 18 Barbers, ... 29 7 5 41 Bartenders, .... 62 2 4 58 Boot and shoe workers. lU 13 19 146 Brewery workers. 23 6 2 31 Building trades, *S JtS 63 m Bricklayers, masons and plasterers. 40 8 3 51 Carpenters, .... 97 16 26 138 Painters, decorators and paperhangers, 78 13 18 109 Plumbers, gasfitters and steamfitters. 43 4 12 59 Other building trades, 35 8 4 47 10 - 10 Cooks and waiters, . 31 7 7 45 Expressmen and shippers. 25 1 1 27 Fanners and farm laborers, . 45 3 5 53 Fishermen and sailors, . 35 5 3 43 Garment trades, 60 21 12 93 Government employees. 54 5 8 67 Janitors and watchmen, 34 8 7 49 Laborers, 185 23 25 233 Longshoremen, 31 4 3 38 Metal trades, .... MH SS u 3U Blacksmiths and horseshoers. 24 1 4 29 Foundry workers. 9 1 10 Iron molders. 24 2 3 29 Jewelry workers, . 6 1 1 8 Machinists, 114 16 24 153 Other metal workers, . 85 16 11 112 Printing trades. 40 7 5 62 Eailroad employees. 147 19 43 209 Retail clerks 96 19 23 138 Rubber workers, 31 4 4 39 Stationary engineers and firemen. 65 8 6 7^ Stone-working trades, . 27 3 2 32 Teamsters, chaufEeurs, drivers and stablemen, r- 256 26 47 329 1 90 SOCIAL INSURANCE. [Jan. Table 6. — Number of Fathers whose Families became Dependent, classified by Occupations of Fathers — Con. OOODPATIONS OF FaTHEBS. Deceased Fathers. Inca- pacitated Fathers. Irre- sponsible Fathers. Total. Textile workers Professiojial and self-employed, Miscellaneous, . , . . . . Not stated, 173 111 263 144 25 11 47 31 31 18 43 44 229 140 353 219 Totals . . 2,649 389 478 3,ns ■ — t Of the 3,297 fathers whose occupations were stated, 404, or 12.2 per cent., were in the building trades, and 341, or 10.3 per cent., were in the metal trades. The principal occupations repre- sented were as follows: teamsters, chauffeurs, drivers and stable- men, 329; laborers, 233; textile workers, 229; railroad employees, 209; machinists, 153; boot and shoe workers, 146; professional and self-employed, 140; retail clerks, 138; carpenters, 138; and painters, decorators and paperhangers, 109. An effort was made to determine, by comparison with cor- responding data, obtained by the census of 1915, whether or not any occupation was more largely represented in the group of fathers of dependent families than in the general population, but owing to differences of classification the data were not strictly comparable. It appeared to be true, however, that the skilled occupations were as fully represented in this group of fathers as in the general male population gainfully employed, although the evidence could hardly be considered as conclusive on this point. In Table B (see page 118) the deceased fathers are classified by occupations and causes of death. The data there presented indicate that the nature of the occupation bears some relation to the number of deaths due to certain diseases and accidents. The data with reference to the four principal causes of death (tuberculosis, pneumonia, accidents and heart trouble) are briefly discussed in the following paragraphs. Tuberculosis. — Of the 2,425 deceased fathers, the causes of whose death were stated, 673, or 27.8 per cent., died of tubercu- losis. As compared with this percentage, the corresponding percentages for the following occupations were high: expressmen 1918.] SENATE — No. 244. 91 and shippers, 56; stone workers, 55.5; printing tradesmen, 41; garment workers, 40.4; bartenders, 36.7; plumbers, 35; and textile workers, 33.7. For the following occupations the percentages were relatively low. fishermen and sailors, 17.2; stationary engineers and firemen, 17.4; painters, decorators and paper- hangers, 19.2; and teamsters, chauffeurs, drivers and stablemen, 20.3. For building tradesmen, taken as a group, the percentage was 28.6, and for metal tradesmen, 29.2. Pneumonia. — This was the cause of death of 332, or 13.7 per cent., of the 2,425 deceased fathers, the causes of whose death were stated. The percentages were relatively high for those engaged in the following occupations: bricklayers, masons and plasterers, 23.1; cooks and waiters, 21.4; teamsters, chauffeurs, drivers and stablemen, 20.3; janitors and watchmen, 19.4; and garment workers, 19.3. For the following occupations the per- centages were low: textile workers, 7.4; blacksmiths, 8.7; govern- ment employees, 9.8; fishermen and sailors, 10.3; printing trades- men, 10.3; carpenters, 10.8; professional and self-employed, 10.8; stone workers, 11.1; railroad employees, 11. "3; and farmers and farm laborers, 11.4. Accidents. — Of the 2,425 deceased fathers whose occupations were stated, 284, or 11.7 per cent., died as a result of accident, and 108 of these deaths were definitely known to have been caused by industrial accident. The occupations showing high percentages of deaths from accidents were: 'fishermen and sailors, 44.8; railroad employees, 25.5; plumbers, 20; longshoremen, 17.2; machinists, 16.4; and laborers, 16.1. For several occupa- tions the percentages were very low: professional and self- employed, 1; garment trades, 1.9; and retail clerks, 5.4. Heart Trouble. — The percentage dying of heart trouble of the 2,425 deceased fathers, the cause of whose death was known, was 8.7. For the following occupations the percentages dying of heart trouble were relatively high: professional and self- employed, 17.6; expressmen and shippers, 16; longshoremen, 13.8; and painters, 12.8. The occupations for which the per- centages were low were: bricklayers, masons and plasterers, 2.6; fishermen and sailors, 3.5; blacksmiths, 4.3; and plumbers, 5. 92 SOCIAL INSURANCE. [Jan. 6. Weekly Wages of Father and Dependency. The earning capacity of the father is a particularly important consideration when viewed in its relation to family dependency. The following table shows that of the total number of fathers (2,495) whose wages were a matter of record, 2,033, or 81.5 per cent., earned less than $20 per week. Of the total number whose weekly earnings were stated, 959, or 38.4 per cent., were in the group earning $15 but less than $20 per week, and 950, or 38.1 per cent., were in the group earning $10 but less than $15 per week. Only 5 per cent, earned less than $10 per week, while only 3.4 per cent, earned $30 or over per week. Table 7. — Number of Fathers whose Families were Dependent, classified by Weekly Wages of Fathers. Weekly Wages of Fathers. Deceased Fathers. Inca- pacitated Fathers. Irre- sponsible Fathers. Total. Under $10, . . . . $10 but less than $15, $15 but less than $20, $20 but lees than $25, $25 but less than $30 $30 and over, . ... Not stated, ... 96 748 742 211 70 46 736 18 112 109 21 17 15 97 10 90 108 39 20 23 188 124 950 959 271 107 84 1,021 Totals, 2,649 389 478 3,516 With reference to the three groups of fathers it was found that of the deceased fathers whose earnings were stated, 17.1 per cent, earned more than $20 per week, and the corresponding percentage for incapacitated fathers was 18.2 per cent., while for the irresponsible fathers it was 28.3 per cent., showing that a larger percentage of irresponsible fathers were earning more than $20 per week than was true of the deceased or incapacitated fathers, or, in other words, there was a larger percentage of families whose fathers were earning $20 or more in the group of families whose dependency was due to the irresponsibility of the father, than in the group of families whose dependency was due to the death of the father, or in the group whose de- pendency was due to the incapacity of the father. 1918.] SENATE — No. 244. 93 7. Amount of Aid received by Families. The more usual range in amount of aid received by the de- pendent families lay between $4 and $9 per week, 71.2 per cent, of the total number of families (3,482) for which the amount of aid was stated having received amounts of at least |4 but less than $9. /Df the 3,482 families concerning which information as to the amount of aid received was reported, 659, or 18.9 per cent., received $5 but less than $6 per week; 544, or 15.6 per cent., received $6 but less than $7 per week; 442, or 12.7 per cent., received $4 but less than $5 per week; and 423, or 12.1 per cent., received $7 but less than $8 per week. In the follow- ing table the data with reference to the amounts of aid received by the dependent families are shown not only for all families taken together, but also separately for those groups of families whose fathers were deceased, incapacitated and irresponsible: — Table 8. — Number of Dependent Families which received Aid, classified by Amounts of Aid received per Week. Amodkts or Aid peb Week. Families of Deceased Fathers. Families of Inca- pacitated Fathers. Families of Irre- sponsible Fathers. Total. Less than S2, 8 1 2 11 $2 but less than $3, . 113 9 20 142 t3 but less than $i . 249 19 48 316 14 but less than S5 359 22 61 442 $5 but less than $6 524 57 78 659 S6 but less than S7 398 60 86 544 t7 but less than 18 295 60 68 423 {8 but less than {9 305 56 51 411 {9 but less than SIO, 149 40 19 208 $10 and over, 225 62 39 326 Amount not stated, 24 4 6 34 Totals, 2,649 389 478 3,516 ... ..., According to the data presented in the foregoing table a larger percentage of the families whose fathers were incapacitated received aid of $6 or more per week than of the families whose fathers were deceased or irresponsible, the respective percent- ages for the three groups of families (based on the number of 94 SOCIAL INSURANCE. [Jan. families for which the amount of aid was stated) having been 71.9, 52.3 and 65.7. Evidently, in granting aid to families whose fathers were incapacitated, the State Board of Charity has recognized the greater need of such families because of the fact that the incapacitated father has not only ceased to provide for his family, but has also become a burden to the family, requiring expenditures on his account. That the amount of aid received by dependent families varies according to the number of dependent children in the family is clearly shown by the data presented in Tables J, K and L (see pages 125 and 126). 8. Number of Children in Family. Two tables are here presented, the one (Table 9) showing the number of children (dependent and non-dependent) in the families covered by this inquiry, and the other (Table 10) show- ing the number of dependent children in these families. On reference to the following table it will be noted that there were comparatively few families in which there was only one child. The families having three children each, numbered 861, or 24.6 per cent, of the total number of families; 833, or 23.8 per cent., had two children each; and 673, or 16.3 per cent., had four chil- dren each. In each of 27 families there were at least 10 children. Table 9. — -Number of Fathers whose Families were Dependent, classified by Number of Children in Family. Number of Chtldben in Family. Deceased Fathers. Inca- pacitated Fathers. Irre- sponsible Fathers. Total. One, Two, , Three, Four, Five, . Six, . Seven, Eight, Nine, Ten or more. Not stated^ Totals, 100 636 632 491 357 208 108 60 30 20 7 71 93 85 61 37 16 10 7 3 13 126 136 97 49 24 15 9 3 4 2 119 833 861 673 467 269 139 79 40 27 2,649 389 478 3,516 1918.] SENATE — No. 244. 95 The following table shows the number of dependent children in the families considered in this investigation. There were two dependent children in each of 1,160, or 33.1 per cent., of the families, and the families with two dependent children each may be considered the typical family receiving mothers' aid. Table 10. ■ Number of Dependent Families which received Aid, classified by Number of Dependent Children in Family. NtJMBEB OF Dependent Childhen IN FAMrLT. Deceased Fathers; Inca^ pacitated Fathers. Irre- sponsible Fathers. Total. One, . . . . 434 27 60 621 Two, ... 888 109 163 1,160 Three, 685 94 132 911 Four, . . ... 367 83 73 623 Five, ... . . 189 41 31 261 Six . . 60 22 15 97 Seven, .... 16 11 1 28 Eight or more. 3 2 2 7 Not stated, . . ... 7 1 8 Totals, 2,649 389 478 3,516 96 SOCIAL INSURANCE. [Jan. III. Summary of Data with Reference to Insurance. 1. Disposition to insure. For the purpose of determining the extent to which insurance was being carried by the fathers and other members of de- pendent families, the following summary table has been pre- pared : — Table 11. — Number of Dependent Families, classified by Causes of Dependency and Disposition to insure. Number of Families. Caxjses of Dependency, AND Insurance or Non-Insurance OF Fathers. One or More Members* (Other than Father) Insured. No Members^ (Other than Father) Insured. Total. Death of Father. 1,801 Sir «,8# Father insured, 1,291 392 1,683 Father not insured 611 455 966 Incapacity of Father. ISS lei SS9 Father insured, 133 31 164 Father not insured 95 130 225 Irresponsibility of Father. m m 478 Father insured 42 6 48 Father not insured, 239 191 430 Totals, . 2,311 1,205 3,616 Father insured 1,466 429 1,895 Father not insured, .' 845 776 1,621 3 » In addition to father, if father was insured. 2 Except father, if father was insured. In each of 2,740 families, or 77.9 per cent, of the 3,516 families included in this investigation, at least one member of the family was insured, and in 1,895, or 53.9 per cent., of the families, the father was insured. Of the 2,649 fathers who died, 1,683, or 63.5 per cent., were carrying insurance at the time of their death; of the 389 incapacitated fathers, 164, or 42.2 per cent, were insured when they became incapacitated; while of the ir- responsible fathers only 48, or 10 per cent., were known to be insured when they ceased to provide for their families. Data 1918.] SENATE — No. 244. 97 with reference to the amounts and nature of insurance carried both by the fathers and other members of- the families are pre- sented in later tables and the text accompanying them. 2. Insurance on Life of Father. (a) Amounts of Insurance. — Examination of the following table shows that of the 1,748 fathers, the amounts of whose insurance were stated, 718, or 41.1 per cent., were insured to the amount of $500 or over, and 375, or 21.5 per cent., to the amount of $1,000 or over. The more usual amounts of insurance carried ranged between $100 and $300, and apparently many of -these policies were taken out primarily for the purpose of paying funeral benefits. There was also a comparatively large number of $500 and $1,000 policies, but very few policies for intermediate amounts were reported. Of the 1,637 deceased fathers, the amounts of whose insurance were stated^ 645, or 39.4 per cent., were insured to the amount of $500 or over, and 324, or 19.8 per cent., were insured to the amount of $1,000 or over. It is of interest to note in this connection that of 527 pay- ments by insurance companies to families of deceased fathers (amounts stated), only 62, or 11.8 per cent., were for amounts of $1,000 or over, whereas of 244 payments (amounts stated) by fraternal orders, 106, or 43.4 per cent., were for amounts of $1,000 or over. In the case of insurance by labor organizations, only 16.4 per cent, of the payments were for amounts of $1,000 or over (see Table M, page 127). Table 12. — Number of Fathers whose Families were Dependent, classified by Amounts of Insurance carried. Amounts of Insdrance oabhied. Deceased Fathers. Inca- pacitated Fathers. Irre- sponsible Fathers. Total. Less than $50 12 - 12 $50 but less than 1100 36 36 $100 but less than $200, . 329 8 337 $200 but less than 1300, . 345 13 1 359 $300 but less than $400, 168 9 2 179 $400 but less than $500, . 102 4 1 107 $500 but less than $600 234 16 2 252 $600 but less than $700 33 2 1 36 $700 but less than $800 17 - - 17 $800 but less than $900 20 1 - 21 $900 but less than 81,000, . 17 - - 17 . . .: 98 SOCIAL INSURANCE. [Jan. Table 12. — Number of Fathers whose Families were Dependent, classified by Amounts of Insurance carried — Con. Amountb of Insukanoe oaehied. Deceased Fathers. Inca^ pacitated Fathers. Irre- sponsible Fathers. Total. $1,000 but leas than tl.lOO, Jl.IOO and over, ... Amount not stated, .... No insurance carried 235 89 4'6 966 35 9 67 225 4 3 34 4301 274 101 147 1,621 Totals 2,649 389 4781 3,516 * Of the 478 irresponsible fathers, 48, or 10 per cent., were known to be insured, and in some cases the families continued to pay the premiimis. For the remaining 430 irresponsible fathers no information relative to insurance of fathers was obtainable, but presumably no insurance for the benefit of the family was being carried by the father. Definite information as to the amount of insurance paid to families upon the death of the father was furnished in 1,623 cases. The total amount paid to these 1,623 families was $802,968.18, or an average of $494.74 per family. Approxi- mately three-fifths (60.7 per cent.) of these families received less than $500 each, the average amount being $227.20 for this group of families, or about $73 more than the average amount ($154.23) spent for burial of deceased fathers by this group of families (see also text on page 105). Facts in further detail with reference to the amounts of insurance received by families of deceased fathers appear in the following table: — Table 13. — • Insurance received by Family upon Death of Father, classifiM by Amounts of Insurance received. Amottnts of Insurance received by Families. Less than $100, $100 but less than $500, $500 but less than $1,000, $1,000 but less than $2,000, $2,000 or over. Not stated. Totals, Number of Insured Fathers. 48 938 318 277 42 60 Total Amount of Insurance. $2,609 80 222,254 36 180,976 00 294,094 00 103,034 00 $802,968 161 ' Of 2,649 fathers whose families became dependent by reason of the death of the father, 1,683, or 63.6 per cent., were carrying life insurance at the time of their death. In 60 cases the amount of the insurance received was either not stated or the whole amount was forfeited for non-payment of dues or other cause. 1918.] SENATE — No. 244. 99 (6) Character of Insurance. — The name of the insurance agency was ascertained in 1,132 cases out of 1,895, where the father was insured at the time of his death or wjien he became incapacitated. In 985 cases the father was insured in one agency only, and in 147 cases he was insured in more than one agency. Of the 985 fathers who were insured in one agency only, 616 carried "company insurance," 279 were insured by fraternal orders, 66 received insurance benefits from labor or- ganizations, and 24 from local relief associations. Summary data with reference to the principal insurance agencies represented appears in Table 14 (page 100), while in- formation in further detail with reference to the agencies furnish- ing insurance and the amounts of insurance appears in Table M on page 127. On reference to the latter table it will be observed that the total number of policies carried by deceased fathers, and regarding which policies, the name of the insuring agency was reported, was 1,172 (including 295 policies carried by 137 fathers who were insured in more than one agency). The Metropolitan Insurance Company was represented by the greatest number of policies, 270 of the deceased fathers having been insured by this company, 228 of whom carried no other insurance. The John Hancock issued policies to 228 fathers, of whom 183 were insured by no other agency. Of the fraternal orders, the Foresters furnished insurance to 97 fathers, of whom 70 were insured in no other agency. Labor organizations paid death benefits to the families of 98 fathers, of whiph families 64 received no insurance or death benefits from any other agency. Similar data with reference to the incapacitated fathers who were insured appears in Table N on page 128. 100 SOCIAL INSURANCE. [Jan. Table 14. — Number of Fathers whose Families were Dependent, classified by Character of Insurance Agency. Caubeb of Dependhnct "■ Classification of Iksubancb Aqencies. Death of Father. In- capacity of Father. Irre- , sponsibility of Father. Total. iTlsurarux Companies. BS7 79 618 Metropolitan Life Insurance Company, 228 24 2S2 John Hancock Life Insurance Company, 183 36 219 Prudentia Jlnsurance Company, . 67 8 75 Other insurance companies 59 11 70 FraterTial Orders. ««S te «79 Foresters,' 70 9 79 Ancient Order of United Workmen, 18 3 21 Royal Arcanum, 14 14 Independent Order of Odd Fellows, 11 11 Knights of Columbus, 7 7 Ancient Order of Hibernians, 11 - 11 Various Jewish orders 31 7 36 Other fraternal orders 91 7 - 98 Labor organizations, 6i 2 - 66 Local relief associations, .... 23 1 - 24 More than one agency,' 137 10 - 147 Not stated 669 46 48 763 No insurance carried, 966 225 430 1,621 Totals, . ... 2,649 389 478 3,516 ' All orders of Foresters were grouped together, because in many instances the original rec. ords failed to state definitely which of the several orders was the insuring agency. 2 In addition to those insured in one agency only there were others carrying insurance in more than one agency. (c) Lapse of Time to Dependency. — The total number of families which received insurance benefits upon the death of the father was 1,683, of which 88 were aided prior to the death of the father. In 1,491 cases the lapse of time between the death of the father and the dependency of the family was stated. In 634, or 42.5 per cent., of these 1,491 cases, the family became dependent in less than six months, but in 429 of these cases the amount of the insurance benefits received by the family was less than $500, and in 377 cases the amount was less than $200, 1918.] SENATE — No. 244. 101 CHART 2. AMOUNT OF INSURANCE (DEATH OF FATHER) AND LAPSE OF mC TO DEPENDENCY OF FAMILY BASED ON A STUDY OF RECORDS OF THE STATE BOARD OF CHARITY XIVERINS 3SIG FAMILIES WHO RECEIVED 'MOTHER'S AID" DURINS THE PERIOD SEPTEMBER 1. 1913 TO SEPTEMBER 11917. ALL AMOUNTS (i.«» cases) LESS THAN #500 (aso cases) #500 BUT LESS THAN #1000 (zst cases) *- 122 -f54+39t->82-4 4 1000 AND OVER .(3°' cases) t67-t45t49+- 148 LEGEND LESS THAN 6 MONTHS ggggggggg^gggg 6 MONTHS BUT LESS THAN ONE YEAR ONE rEAR BUT LESS THAN 2 YEARS ~\ Z YEARS AND OVER 102 SOCIAL INSURANCE. [Jan. or hardly more than sufficient to pay the burial expenses of the father. Of the 860 families which received insurance benefits of less than $500 each, 429, or 49.9 per cent., became dependent in less than six months, and of the 607 families which received insurance benefits of $500 or more each, 190, or 31.3 per cent., became dependent in less than six months, showing that in general it was true that the length of the period between the death of the father and the dependency of his family was greater in those cases where the larger amounts of insurance benefits were received. There were many exceptions, however, to this rule. Thus, it was found that of the 309 families which received insurance benefits of $1,000 or over on the death of the father, 67, or 21.7 per cent., became dependent in less than six months, 112, or 36.2 per cent., in less than one year, and more than one-half (52.1 per cent.) became dependent in less than two years. The number of families which did not become dependent within five years after the receipt of the insurance money was 181, or 12.1 per cent., of the total number (1,491) for which the lapse of time to dependency was stated. Furthermore, of the 860 families which received less than $500 each, 91, or 10.6 per cent., did not become dependent within five years after the death of the father. It is evident, therefore, that in many cases some source of income other than the insurance money received upon the death of the father enabled the families to postpone the date of dependency. Chart 2, appearing on the preceding page, illustrates graphi- cally the effect which the receipt by families of insurance money on the death of the father had upon the deferring of their de- pendency. It is evident that in the case of the group of families which received less than $500 the insurance money did not serve to defer dependency to the extent that the larger amounts did so serve in the case of families which received $1,000 or over. In the case of the group of families which received $500 but less than $1,000 the money served in a measure to defer dependency beyond the period of six months, but the percentage of families which became dependent within two years was almost identical with the corresponding percentage of families which received less than $500. 1918.] SENATE — No. 244. 103 Information in detail with reference to amounts of insurance and lapse of time to dependency appears in Table O on page 129, and the data there presented are summarized in Table 15, below. Table 15. — Number of Dependent Families whose Fathers were Insured at the Time of Death, classified by Amourds of Insurance and Lapse of Time to Dependency. Amounts of Insubance. ' Lapse of Time to Dependency. $100 but less than $500. $500 but less than $1,000. $1,000 but less than $2,000. $2,000 and over. Amount not stated. Total. Less than six months. Six months but leas than 1 year One year but less than 2, . Two years but less than 3, Three years but less than 4, Four years but less than 5, Five years but less than 10, Ten years or over. Aided prior to death of father. Not stated 429 94 101 53 51 41 81 10 65 77 123 54 39 21 16 10 33 2 18 5 63 44 42 35 18 28 33 7 7 4 4 1 7 7 4 3 12 1 2 2 15 2 2 1 2 2 6 16 634 195 191 117 89 84 161 20 88 104 Totals, 992 321 281 43 46 1,683 ... _, (d) Purposes for which expended. — The aggregate amount of insurance benefits on account of death of fathers, received by 1,623 dependent families, was $802,968.16, or an average amount of $494.74 per family. An endeavor was made to ascertain from the family records the amount expended by each family for burial expenses, doctor's bills, debts, living expenses and other purposes. For a large number of families definite informa- tion of this character was not obtainable, ' but it was possible to prepare an itemized statement covering expenditures amount- ing to $319,433.76. This information is presented in detail in Table P on page 130, and summary data derived therefrom are shown in the following table : — 104 SOCIAL INSURANCE. [Jan. Table 16. — Insurance Benefits received by Families upon the Death of the Father, classified by Principal Purposes for which expended. Families receiv- ing Benefits OF Less than J600. Families beoeiv- ING Benefits OF $600 OH Over. All Families. Expended. Amounts. Per- cent- ages.! Amounts. Per- cent- ages.! Amounts. Per- cent- ages.' Burial, Doctor's billa, . Debts, living expenses, Other purposes, S82,684 21 4,039 00 27,091 97 34,128 68 5,729 00 53.8 2,6 17.7 22,2 3,7 $23,867 40 3,959 00 28,085 00 67,012 60 42,837 00 14.4 2,4 17,0 40,4 25.8 $106,551 61 7,998 00 55,176 97 101,141 18 48,566 00 33,3 2,5 17.3 31,7 15.2 Totals (purposes of expendi- ture stated). Totals (purposes of expendi- ture not stated). $163,672 86 187,458 30 100,0' $165,760 90 296,076 10 100,0' -1 $319,433 76 483,534 40 100,0' Totals (all expendi- tures). 9341,131 16 -1 $461,837 00 -' $802,968 16 -1 ' The percentages are based on the total amount itemized. According to the data presented in the above table, burial expenses constituted 33.3 per cent, of the total expenditures ($319,433.76) for all families whose expenditures were itemized. The next largest item was living expenses, constituting 31.7 per cent., followed in order of importance by debts, 17.3 per cent.; other purposes (principally investments), 15.2 per cent., and doctor's bills, 2.5 per cent. Families receiving small amounts of insurance benefits expended for burial purposes a dispropor- tionately large part of the insurance benefits received, and, consequently, after paying burial expenses, doctor's fees and debts there was available for the payment of living expenses and for other purposes a comparatively small margin. For the purpose of illustrating this point the families were classified in two groups, namely, those receiving less than $600 and those receiving $600 or more. Families of the first group expended ' 53.8 per cent, of the total for burial purposes, whereas families of the second group expended only 14.4 per cent, for such pur- poses. The percentages expended by families of the first group on account of doctor's bills and debts did not vary greatly from the corresponding percentages for the second group, but 1918.] SENATE — No. 244. 105 the expenditures on account of living expenses constituted 22.2 per cent, of the total amount expended by families of the first group, as compared with 40.4 per cent, by families of the second group; while for other purposes (principally investments) families of the first group expended only 3.7 per cent., while families of the second group expended 25.8 per cent. In 632 cases the cost of burial of the deceased father was stated, and for these 632 cases the average cost per burial was $168.59. The average cost per burial in 527 cases, where the amount of insurance benefits received was less than $600, was $156.90, and for 105 cases, where the amount of insurance benefits received was $600 or over, the average cost per burial was $221.21. The average expenditures on account of doctor's bills in 108 cases, where the expenditures on this account were stated, were $74.05; the average expenditures on account of debts, based on records furnished by 264 families, were $209; for living expenses (292 families), $346.37; and for other expenses, principally invest- ments (85 families), $571.36. (e) Occupations of Insured Fathers. — For the purpose of determining what proportion of the fathers in the several occu- pations were insured, the insured fathers were classified by occu- pations as shown in Table 17, below. By comparing these data with corresponding data presented in Table 6 on page 89, one can determine the percentages insured of the total number of fathers in any one of the specified occupations. Of the 3,516 fathers considered in this inquiry, 1,895, or 53.9 per cent., were insured. In general, it was true that the per- centage insured of the total number in the occupation did not vary to any large extent for the various occupations. For several occupations, however, the percentages were found to be considerably higher than the average (53.9) for all occupations- taken as one group, namely, bartenders, 82.8; longshoremen, 78.9; expressmen and shippers, 66.7; blacksmiths, 65.5; iron molders, 65.5; printing trades, 65.4; and stoneworkers, 62.5. On the other hand, comparatively small percentages of those in the following occupations were insured: farmers and farm laborers, 33.9; carpenters, 36.9; fishermen and sailors, 46.5. For the metal trades and building trades, the respective per- centages were 58.9 and 47.3. 106 SOCIAL INSURANCE. [Jan. Table 17. — Number of Fathers who carried Insurance, classified by Occu- pations. OcOnPATIONS OF Fathebb. Deceased Fathers. Bakers, Barbers Bartenders, Boot and shoe workers Brewery workers Building trades, Bricklayers, masons and plasterers, . Carpenters, Painters, decorators and paperhangera. Plumbers, gasfitters and steamfitters. Other bmlding trades, . . . . Cigar makers Cooks and waiters, Expressmen and shippers, . . . " ■ Farmers and farm laborers Fishermen and sailors Garment trades, Government employees, . . . . Janitors and watchmen, . . . . Laborers, Longshoremen, Metal trades . Blacksmiths and horseshoers. Foundry employees Iron molders, Jewelry workers Machinists Other metal workers, Printing trades Railroad employees Hetail clerks, . . . i . . . Rubber workers, Stationary engineers and firemen, . Stone-working trades, Teamsters, chaufEeurs, drivers and stablemen, 8 17 46 69 14 m 25 4S 49 25 24 5 17 17 17 20 41 36 24 109 24 m 18 5 19 52 61 24 41 20 181 Inca- pacitated Fathers. 1 2 3 2 16 2 4 1 1 7 4 5 9 4 17 1 4 12 12 2 5 10 Irre- sponsible Fathers. Total. 10 19 48 75 17 191 28 SI 55 28 29 5 21 18 18 20 48 41 29 120 30 lot 19 5 19 3 34 114 75 26 47 20 195 1918.] SENATE — No. 244. 107 Table 17. — Number of Fathers who carried Insurance, classified by Occu- pations — Con. OoOtrPATIONS OF Fatheks. Deceased Fathers. Inca- pacitated Fathers. Irre- sponsible Fathers. Total. Textile workers, Professional and self-employed, Miscellaneous, Not stated, no 66 164 75 13 4 17 9 2 2 6 6 125 72 186 90 Totals, 1,683 1G4 48 1,895 (/) Weekly Wages and Amounts of Insurance. — For the pur- pose of determining whether or not the amount of policies taken out by the fathers of dependent families were generally larger in the case of fathers who received high rates of wages than in the case of those who received low rates, the following table was prepared : — Table 18. — Number of Deceased Fathers who were Insured at Tims of Death, classified by Amounts of Insurance carried, and Weekly Wages of the Father. [Note. — Of 2,649 fathers whose families became dependent on account of the death of the father, 1,683, or 63.5 per cent., were carrying life insurance at the time of their death,] Weekly Wages op Fathee. ' Amounts op Insdrance. Under $10. $10 but less than $15: $15 but less than $20. $20 but less than $25. $25 but less than $30. $30 and over. Not stated. Total. Less than 150 4 6 2 12 $50 but less than $100, 1 11 11 1 1 1 10 36 $100 but less than $200, 12 104 107 17 5 2 82 329 $200 but less than $300 9 101 115 26 6 2 ■ 86 346 $300 but less than $400 2 67 64 14 6 1 35 168 $400 but less than $500 5 38 22 12 i 21 102 $500 but less than $600 8 70 65 26 5 3 58 234 $600 but less than $700 10 10 2 - 1 10 33 $700 but less than $800 4 2 4 7 $800 but less than $900 6 6 2 1 1 4 $900 but less than $1,000, . 3 4 7 1 2 ! 108 SOCIAL INSURANCE. [Jan, Table 18. — Number of Deceased Fathers who were Insured at Time of Death, classified by Amounts of Insurance carried, and Weekly Wages of the Father — • Con. Weekly Wages OF Fatheh. Amounts of Insuhamce. Under $10. $10 but less than $16. $15 but less than $20. $20 but less than $25: $25 but less than $30. $30 and over. Not stated. Total. $1,000 but less than $1,100, 2 47 95 21 12 6 52 235 Jl,100 but less than $1,200, 1 3 2 1 1 8 $1,200 but less than $1,300, 5 2 2 - 1 1 11 $1,300 but less than $1,400, 2 1 3 $1,400 but less than $1,500, 1 2 I - 4 $1,500 but less than $1,750, 2 3 1 2 8 16 $1,750 but less than $2,000, 1 1 1 - 1 - 4 $2,000 and over. 3 9 6 7 3 15 43 Not stated, . 2 11 16 4 2 11 46 Totals, 41 479 53S 148 1 48 27 405 1)683 Of the 1,026 fathers whose wages were less than $20 per week, 78.2 per cent, carried insurance ,of less than $600 each, and 17.4 per cent, carried insurance of $1,000 or over, while of the 217 fathers whose wages were $20 or over, 59.9 per cent, were insured for less than $600, and 31.2 per cent, were insured for $1,000 or over. These facts indicate that the fathers whose wages were comparatively high were less disposed to insure for small amounts and more disposed to insure for large amounts than the fathers whose wages were low. It does not appear, however, that the amounts of insurance carried were by any means proportionate to the weekly wages of the fathers. In fact, a large percentage of the fathers receiving comparatively high rates of wages were insured for small amounts. Chart 3, appearing on the opposite page, illustrates graphi- cally the relation between the .amounts of insurance carried and the weekly wages of the fathers prior to their death. The three graphs representing, respectively, facts with reference (1) to all insured fathers, (2) fathers whose weekly wages were less than $15, and (3) fathers whose weekly wages were $20 or over, show a marked correspondence in their fluctuations. The wide diver- gence, within certain limits, of the dotted line from the thin unbroken line illustrates the fact that fathers receiving 1918.] SENATE — No. 244. 109 CHART 3. AMOUNT OF INSURANCE (DECEASED FATHERS) AND WEEKLY WAGES OF FATtiERS PRIOR TO DEATH BASED OH A STUDY OF RECORDS t)F THE STATE BOARD OF CHARITY qOVaiNS 3516 FAMILIES WHO RECEIVED 'MOTHER'S AID" DURING THE PERIOD SEPTEMBER 1,1913 TO SEPTEMBER 1.1917. NOTE-THE 6RAPHS BELOW REPRESENT DATA COVERING 1214 DECEASED FATHERS RECAROINS WHOM BOTH THE AMOUNT OF INSURANCE AND THE WEEKLY WA6ES WERE KNOWN. nRCEHT INSURED Z5l 20 AMOlfHT OF) JKuuNcc ; // ''' \ \ ' ' '' ' . UNKII Ino- tZOO- 1300- $400- tSOO- teOO- 470D- (800- tsoo- tiooo- tllOO- im «200 1300 t400 tsoo 1600 .trOO tsoo 1900 tlOOO IIIOO MOOVER LEGEND ALL INSURED FATHERS, IRRESPECTIVE OF WEEKLY WAGES FATHERS WHOSE WEEKLY WAGES WERE LESS THAN $ 15.00 FATHERS WHOSE WEEKLY WAGES WERE J 2O00 OR OVER no SOCIAL INSURANCE. [Jan. more per week were, as a group, less inclined to insure for the smaller amounts ranging between $100 and $300 than were the fathers who received $15 or less per week, while, on the other hand, the fathers included in the first group were more inclined to insure for the larger amounts ranging between $900 and $1,100 than were those included in the second group. The tendency of the two curves to coincide between the points repre- sented by the amounts $400 and $600 indicates that there was no more pronounced disposition on the part of the fathers receiving the higher rates of wages to insure for amounts ranging between $400 and $600 than on the part of those receiving lower rates of wages. S. Insurance of Members of Family, (a) Number of Members insured. — In each of 2,311 families, or 65.7 per cent, of the total number of families covered by this inquiry, there were one or more insured members, not including deceased fathers who may or may not have been insured. In Tables T, U and V, on pages 136 to 138, data in detail with reference to the number of members insured . are presented, and these data are summarized in the following table: — Table 19. — Number of Dependent Families, One or More Members ' of which were Insured, classified by Number of Insured Members in Family. Number of Families of — NuMBEH OP Insured Members IN Family.! Deceased Fathers. Inca- pacitated Fathers. Irre- sponsible Fathers. Total. One Two, . . . . Three, ... . . Four, . ... Five, .... . . Six, . . . Seven, . . . Eight, . ... Nine, Ten or more. Not stated 136 173 404 324 243 15S 98 SO 24 20 172 21 17 27 45 38 27 10 8 7 1 27 20 27 72 68 23 24 3 7 2 7 28 177 217 503 437 304 209 111 65 33 28 227 Totals, .... 1,802 228 281 2,311 * Deceased fathersi who were insured, were not included. 1918.] SENATE — No. 244. Ill It will be observed that there was only a comparatively small number of families having only one member insured. In each of 750 families, or 36 per cent, of the 2,084 families which reported the number of insured members, 5 or more members were insured, and there were 28 families having 10 or more insured members. Many of the policies, however, were for small amounts, and the insurance was evidently intended in most cases to cover burial expenses only. The aggregate number of persons insured, as reported by the 2,084 families which reported the number of insured members, was 8,516, or an average of 4.1 persons insured per family. This remarkable showing is evidence of the thoroughness of the canvass of families of wage earners, made by insurance solicitors representing the so-called industrial insurance companies. (6) Character of Insurance. — The names of the insurance agencies by which the members of dependent families were insured were reported by 1,761 families. There were 1,534 families, the members of which were insured by one agency only, and of this number, 1,481, or 96.5 per cent., carried "com- pany insurance," while only 53, or 3.5 per cent., were insured by other agencies. Of the 877 deceased fathers insured by one agency only, 340, or 38.8 per cent., were insured by agencies other than insurance companies (see Table 14 on page 100). It thus appears that the companies were less successful in placing insurance among the fathers than among other members of the families. Summary data with reference to the principal insurance agencies represented appear in Table 20, below, and data in further detail with reference to these agencies and the number of members insured appear in Tables T, U and V on pages 136 to 138. 112 SOCIAL INSURANCE. [Jan. Table 20.— Number of Dependmt Families, One or More Members^ of which were Insured, classified by Character of Insurance Agency. Number of Familibs of — ChABACTEB of iNSnBANCB Agbnct. Deceased Fathers. Inca- pacitated Fathers. Irre- sponsible Fathers. Total. Insurance Companies, /,J«S US tao l.iSl Metropolitan life Insurance Company, 556 76 gi 723 John Hancock Life Insurance CJompany, . 390 48 64 502 Prudential Life Insurance Company, . 172 17 21 210 Other insurance companies. 40 2 4 46 Fraternal Orders. SI 6 B S9 Foresters, 8 2 1 11 Other fraternal orders, 23 4 1 28 Local relief associations, .... 9 1 4 14 More than one agency 180 26 21 227 Not stated, . . . . . . 424 52 74 550 Totals, .... ' .. . 1 , r, r, 1,802 228 281 2,3U ^ Deceased fathers, who were insured, were not included. (c) Cost of Insurance arid Weekly Income of Family. — It was possible to ascertain for nearly all of the families, one or more members of which, were insured, the weekly cost of insurance of the members and the weekly income of the family. These data are presented in detail in Tables W, X and Y on pages 139 to 141, and from these tables the following summary table has been derived: — 1918.] SENATE — No. 244. 113 Table 21. — Number of Dependent Families, One or More Members of which were Insured, classified by Weekly Cost of Insurance and Income of Family.. Weekly Income op Family. Weekly Cost of IXSUBANCE PER FaMILT. Under 15. $6 but less than $10. $10 but less than $16. $15 but less than $20. $20 but less than $25. $25 but less than $30. $30 and over. Not stated. Total. Less than 20 cents, . 20 cents but less than 30 cents. 30 cents but less than 40 cents. 40 cents but less than 50 cents. 50 cents but less than 60 cents. 60 cents but less than 70 cents. 70 cents but less than 80 cents. 80 cents but less than 90 cents. 90 cents but less than $1, . 51 but less than $1.25, . $1.25 and over. Not stated, . 15 15 19 10 2 3 2 1 1 2 108 194 196 120 99 45 26 17 7 14 9 15 83 143 171 124 137 80 54 27 15 16 14 18 18 31 42 52 57 34 18 20 11 23 7 3 2 9 6 10 8 13 7 7 6 7 4 1 2 2 2 1 2 1 3 5 5 6 1 3 1 2 1 1 1, 2 8 12 10 7 8 10 3 5 1 3 4 1 235 406 446 328 313 189 112 80 47 69 46 40 Totals, 70 850 882 316 79 31 11 72 2,311 =3 Of the 2,271 families for which the cost of insurance was stated, 1,415, or 62.3 per cent., expended less than 50 cents per week for this purpose, and 94.9 per cent, expended less than $1 per week. The more usual expenditures ranged between 20 and 60 cents per week, and the largest number of famihes included in any of the specified groups was 446, — the group which paid 30. cents but less than 40 cents per week. Of the 2,239 families, the weekly income of each of which was stated, 920, or 41.1 per cent., received a weekly income of less than $10; 1,198, or 53.5 per cent., received $10 but less than $20; and 121, or 5.4 per cent., received $20 and over. For each of 2,200 families both the weekly cost of insurance and the weekly income of the family were stated. In order to determine whether the expenditures for insurance bore any direct relation to the amount of income of these families, the families have been considered in three groups, namely, those having an income of less than $10 per week, those having an income of $10 but less than $20 per week, and those having an income of $20 per week. Of the 903 families in the first group, 677, or more 114 SOCIAL INSURANCE. ' [Jan. or 75.0 per cent., paid less than 50 cents per week for insurance; of the 1,177 families in the second group, 56.4 per cent.; and of the 120 families in the third group, 30.8 per cent. For these three groups of families the percentages expending f 1 or more per week for insurance were, respectively, 2.5, 5.1 and 20.8. These facts indicate that the families whose incomes were rela- tively high, as a rule, expended more for insuramce than did those families whose incomes were small, but it does not appear that the expenditures for insurance were by any means pro- portionate to the amount of the income. 1918.] SENATE — No. 244. 115 Appendix, DETAILED STATISTICAL TABLES. Table A. Number of Deceased Fathers, classified by Causes of Death of Fathers and Age at Death. Table B. Number of Deceased Fathers, classified by Causes of Death of Fathers and Occupations at Time of Death. Table C. Number of Incapacitated Fathers, classified by Causes of Incapacity of Fathers and Age Groups. Table D. Number of Incapacitated Fathers, classified by Causes of Incapacity of Fathers and Occupations of Fathers. Table E. Number of Irresponsible Fathers, classified by Age Groups and Nature of Irresponsibility. Table F. Number of Irresponsible Fathers, classified by Occupations of Fathers and Nature of Irresponsibility. Table G. Number of Deceased Fathers, classified by Weekly Wages of Fathers at Time of Decease and Number of Children in Families. Table H. Number of Incapacitated Fathers, classified by Weekly Wages Prior to Incapacity and Number of Children in Families. Table I. Number of Irresponsible Fathers, classified by Weekly Wages and Number of Children in Families. Table J. Number of Families of Deceased Fathers which received Aid, classified by Amounts of Aid and Number of Dependent Children in Families. Table K. Number of Families of Incapacitated Fathers which received Aid, classified by Amounts of Aid and Number of Dependent Children in Families. Table L. Number of Families of Irresponsible Fathers which received Aid, classified by Amounts of Aid and Number of Dependent Children in Families. Table M. Number of Deceased Fathers who were Insured at Time of Death, classified by Amounts of Insurance carried and Character of Insur- . ance Agencies. Table N. Number of Incapacitated Fathers who were Insured, classified by Amounts of Insurance and Character of Insurance Agencies. Table O. Number of Deceased Fathers who were Insured at the Time of Death, classified by Amounts of Insurance and Lapse of Time to Dependency of Families. Table P. Insurance received by Families upon Death of Father, classified by Amounts and Purposes for which expended. Table Q. Number of Deceased Fathers who carried Insurance, classified by Amounts of Insurance carried and Occupations. Table R. Number of Incapacitated Fathers who were Insured, classified by Amounts of Insurance and Occupations of Fathers. Table S. Number of Irresponsible Fathers who were Insured, classified by Amounts of Insurance and Occupations of Fathers: Table, T. Number of Dependent Families of Deceased Fathers, One or More Members of which Families were Insured, classified by Character of Insuran'ce and Numbers of Members covered. Table U. Number of Dependent Families of Incapacitated Fathers, One or More Members of which Families were Insured, classified by Char- acter of Insurance and Numbers of Members covered. 116 SOCIAL INSURANCE. [Jan. Table V. Number of Dependent Families of Irresponsible Fathers, One or More Members of -which Families were Insured, classified by Character of Insurance and Numbers of Members covered. Table W. Number of Dependent Families of Deceased Fathers, One or More Members of which Families were Insured, classified by Weekly Cost of Insurance and Weekly Income of Families. Table X. Number of Dependent Families of Incapacitated Fathers, One or More Members of which Families were Insured, classified by Weekly Cost of Insurance and Weekly Income of Families. Tab7.e Y. Number of Dependent Families of Irresponsible Fathers, One or More Members of which Families were Insiu-ed, classified by Weekly Cost of Insurance and Weekly Income of Families. .1918.] SENATE — No. 244. 117 ' Table A. — Number of Deceased Fathers, classified by Causes of Death of Fathers and Age at Death. Age at Death. =r — 3 Causes of Death. «| w !x >^ i» >H. > i» !« i» 1 .s S n ^ ? ^ S ■s 1 e.3 s )S ^ s S J, s to ll H Tuberculosis, 10 68 192 l.iiS 140 .M 36 6 1 ?1 673' Pneumonia, 7 25 63 98 66' 37 14 6 9 _ 7 332 Accident ,5 »8 70 .W Sd 27 15 5 _ fl 2842 Kidney trouble, . 1 27 31 41 48 34 18 5 1 1? 4 212 S ft 24 41 17 24 5 3 1 3 127 Apoplexy, etc., 1 7 13 19 28 16 8 5 2 3 I 103 Cancer, .... 1 ft 11 18 21 21 14 5 2 1 2 102 Alimentary system, diseases oi, . . . . 2 .■> 12 24 16 17 3 2 1 _ ■ 2 84 Typhoid fever, . .■i 13 12 18 10 6 2 2 _ 3 71 Complication of diseases, - 7 14 12 IS 7 2 2 3 _ 62 Suicide ti 4 8 8 16 4 2 1 1 2 _ 48 Insamty, - 2 8 5 15 12 1 1 2 46 Blood poisoning, Appendicitis, — 5 a 13 fi B 2 3 - - 40 » 4 S 12 6 3 1 2 - _ 1 37 Bespiratory system, diseases of, .... . 1 3 S 3 7 4 1 2 1 1 _ 28 Murdered 1 2 8 1 _ 12 Other causes. ft 17 29 41 27 25 9 2 1 2 5 164 Not stated, .... 3 13 41 44 45 22 8 9 7 2 30 224 Totals SO 251 546 619 S43 31S 130 61 30 14 90 2,649 ' 1 Of this number, 58 were cases in which tuberculosis was a contributory cause. 2 Of this number, 108 were definitely known to have been cases of industrial accident. 118 SOCIAL INSURANCE. [Jan. ^ 1 I pq n 1 •si^^ox SSSS3S|§feSSSSSS5S§SSSSS|S='S'=3g •pa-i^^B ^oj\i ^Mcooo^oi^'* 1 cothmco I ^ CO 00 eo CO t;j (N ^ w ^ eg ^ ->»< eo •sasnBo aaii^o 1 1 t-o 1 us ■<*< i-H U5 CO N I « >-i *-< N eo CO i-H o 1 toMiHi-i 1 oeo JO sas^asTQ aaq^O 1 ^ 1 il 1 1^1 1 ■si^Toipuaddv 1 1 1 M 1 *tSWC-»-lt»l |«l^i-l •mat -s.^g .iCju^aacuitv 9T\% }0 SaSBaSTQ 1 eqcsiM 1 « I MO I M^ 1 I .-( ca oj I 1 |T(<(Neo'*^eow«»'*l4^•coeocoeo I iMi-teq I Mcq(M,-iTtti-( i-H^^Tieo I mM.-no i cqml l< CO I 3 S s 1 s 11 1 1 H Tuberculosis, Insanity, Apoplexy, etc.. Heart trouble Blindness, Crippled, Kidney trouble, . . . . Alimentary system, diseases of, . Cancer, Accident, Other causes. Not stated, ... 26 2 1 1 1 34 14 2 2 1 1 1 5 46 32 5 1 2 ? 1 8 1 48 27 S 6 1 2 1 7 23 14 4 2 1 1 1 1 4 •9 3 1 1 2 1 3 2 1 1 1 2 2 2 1 1 7 3 2 1 1 1 191 107 21 13 6 6 5 S 4 2 27 2 Totals, . L_ 31 > 60 102 97 47 21 8 4 i IS 389 1 1 There were no cases of fathers under 25 years of age to be included in this tabulation. 1918.] SENATE — No. 244. ' 121 ^ I- ss e s S5> PS, I i 3 ^ll|fH|||||||||^|||||| 1 M^^ 1 t,.rt«l«l 1 1 I I I I rtrt I ^^■.-, I I I w I 'llll-^ll^llllllllli-Hlllllll ll1ll>Hll^I||||||||||-.-*|11rt( I I I I I I I I I 1 I ^ I I I I 1 I 1 I I 1 I I I I I I I W I -SlT-. I I I tH 1 I t-H 1 t I I 1 I I I I I I [ Ill'-Hl^^l^llli-Illl.-Il^llllllll 1 I I I I 1 I I I I I I I I I i-<^ I ^ I I I 1 [ I I I 1 I I isili-il 1^1 I I I.H1 imi-Mi I l^-ll I ^ 1 I I 'QWN.-t 1^1 I I |(M| l»-t|^| I I 1^ I T-t I eoec&seoioco I r-ii^ i mcocoi-h | coi-i©jtHth i loio HlM^t^COeo«CO'*CO-*"*'-l I NC<1MI>CC^<» 1 i-H^t^O ?S -J "St. cS ffi S O N ^ s - ho n ■dT3 +5 -u M - Ja »-i _5 ^ I tl i|^ ^ 11 a Sis a~1g 111 lfl H .« XJ 1^ rQ Ja a -a s S .a >, V -a ■n a n =:! 3 .0 ^ 5 ^ ■a +3 >. a ,i3 d ?> s 1 m & I e & I 1^ I E-i if ^71 > Of this number, 196 were reported to have been addicted to the use of alcohol, classified as follows: deserted, 170; divorced, 6; separated, 6; imprisoned, 14. Table F. — Number of Irresponsible Fathers, classified by Occupations of Fathers and Nature of Irresponsibility. Occupations of Fathers. Bakers, Barbers, . . . . . Bartenders Boot and shoe workers. Brewery workers, .... Building trades, Bricklayers, masons and plasterers. Carpenters Painters, decorators and paper- hangers, ' Plumbers, gaafitters and steam- fitters, Other building trades. Cooks and waiters, .... Expressmen and shippers, . Farmers and farm laborers. Fishermen and sailors. Garment trades, Government employees, Janitors and watchmen, Laborers Longshoremen, . . . . Metal trades, . . . • • Blacksmiths and horseshoers, . Foundry workers, .... Iron molders,' jewelry workers. Machinists, . . • • • Other metal trades, . Printing trades, . . ■ ,• , • EaUroad employees (steam and elec- tric), . ; . . . . Retail clerks, , . ■ - Rubbei: workers, . . Stationary engineers and firemen. Stone-working trades, .. • • Teamsters, chauffeurs, drivers and stablemen. Textile workers, . • , ■ , ■ Professional and self-employed, . Miscellaneous, . . . . Not stated Totals, Deserted. Divorced. Separated. Im- prisoned. 4 18 S6 2 24 12 3 7 1 4 3 10 6 7 24 2 3? 4 1 3 1 19 39 20 4 5 1 41 25 13 35 34 406 18 11 43 Total. 4 5 4 19 2 es 3 26 12 4 7 1 5 3 12 8 7 25 3 u i 1 3 1 24 11 5 4 6 2 47 31 18 478 124 SOCIAL INSURANCE. [Jan. Table G. ■ — Number of Deceased Fathers, classified by Weekly Wages of Fathers at Time of Decease and Number of Children in Families.'^ NUMBEB OF FaTHEES WHOSE WEEKLY WAGES WEBE — NnMBEH OF Childbbn IN Families. ^ Under $10 $15 but less but less $20 but less $25 but less $30 and Not Total. $10. than than than than ■ over. stated. $15. $20. $25. $30. One, .... 6 20 31 7 3 _ 33 100 Two, . ... 24 183 183 47 12 11 176 636 Thiee, 15 184 185 47 16 9 176 632 Four 17 137 134 45 8 6 144 491 Five, 15 98 109 29 14 6 86 357 Six, . ... 3 65 48 16 9 8 59 2q8 Seven, .... 8 28 29 9 3 2 29 108 Eight 3 17 10 5 1 1 23 60 Nine, ... 3 11 7 4 2 2 1 30 Ten or more, 1 5 4 2 2 1 5 20 Not stated. 1 2 4 7 Totals, 96 748 742 211 70 46 736 2,649 * Includes all, whether over 14 years of age or not, who were being supported by father prior to his death. Table H. — Number 'of Incapacitated Fathers j classified by Weekly Wages Prior to Incapacity and Number of Children in Families.^ NuMEEE OF Incapacitated Fatheeb whose Weekly Wages webs — Ndmeeb of Childeen IN Families. 1 Under $10. $10 but less than $15. $15 but less than $20. $20 but less than $25. $25 but less than $30. $30 and over. Not stated. Total. One, . Two, ... Three Four Five, . Six, . Seven, Eight, Nine, . Ten, .... 1 4 7 3 2 1 1 21 26 24 20 7 7 2 2 2 2 19 28 23 14 14 3 4 1 1 3 6 1 7 2 2 5 4 5 2 1 4 4 3 1 3 2 19 21 25 14 11 3 2 6 71 93 85 61 37 16 10 7 3 Totals, 18 112 109 21 17 15 97 389 1 Includes all, whether over 14 years of age or not, who were being supported by father prior to his incapacity. 1918.] SENATE — No. 244. 125 Table I. — Number of Irresponsible Fathers, classified by Weekly Wages and Number of Children in Families.'^ NUMBEB OF IhRESPONSIBLE FaTHEBS WHOSE Weekly Wages wehe — Number of Childhen TN FamU'Ies.i Under $10. $10 but less than $15. $15 but less than $20. $20 but less than $25. $26 but less than $30. $30 and over. Not stated. Total. One, . Two, Three, Four, . Five, . Six, . Seven, Eight, . Nine, . Ten and over, Not stated. 1 1 3 i 1 2 29 21 15 10 3 2 2 1 1 1 3 28 30 20 15 6 i 1 2 •1 4 14 S 4 3 3 2 1 6 2 3 4 1 2 1 5 7 5 1 3 2 6 63 66 42 . 16 10 1 2 2 1 13 126 136 97 49 24 15 9 3 4 2 Totals, 10 90 108 39 20 23 188 478 F : > Includes all, whether over 14 years of age or not, who were being supported by father prior to his leaving the family. Table J. — Number of Families (of Deceased Fathers) which received Aid, classified by Amounts of Aid and Number of Dependent Children in Families. . Nttmber of Families RECEIVING Specified Amounts OF Aid per Week. NUMBEH or DEPENDBNa $2 $3 $4 $6 $6 $7 $8 $9 Childben Less but but but but but but but but $10 Not stated. IN Families , than less lesB less" less less less less less and Total. $2. than than than than than than than than over. $3. $4. $5. $6. $7. $8. $9. $10. One, 4 66 84 98 B7 49 22 9 4 4 7 434 Two, 4 43 94 155 230 174 78 63 17 26 4 888 Three, 11 47 70 128 98 124 111 49 42 6 685 _ 2 18 26 48 62 44 76 47 50 4 367 Five, _ . 4 8 14 18 18 36 22 66 3 189 Six, _ 1 1 5 6 6 8 9 23 1 60 Seven, _ - - - 1 2 - 1 12' - 16' Eight, - - - - 1 - - - - 2 - 3 Not stated, - - 2 1 1 ~ 1 2 ~ " " Tot I lis. 8 113 249 359 624 398 295 305 149 226 > 24 2,649 > ' Of this number only three families received aid to the amount of $16 or over, and the largest amount of aid paid was $18 a week in one case. 126 SOCIAL INSURANCE. [Jan, Table K. — Number of Families of Incapacitated Fathers which received Aid, classified by Ammints of Aid and Number of De-pendent Children in Families. Number OF Familibs RECEiviNa Specified Amounts OF Aid per Week. Number of DEPENDBira $2 $3 $4 $5 $6 $7 $8 $9 Children Less but but but but but but but but $10 Not stated. TN Families . than IPJIR leas lefls less less lens less less and Total. $2. than than than than than than than than over. $3. «. $5. $S. $7. $8. $9. $10. One, . 1 3 2 3 2 10 2 2 _ 2 _ 27 Two, 3 9 10 29 20 15 11 9 3 - 109 Three, _ 4 4 13 17 23 15 12 6 - 94 Four, - 2 2 4 7 5 14 17 13 17 2 83 Five, _ 1 1 1 2 5 2 6 5 17 1 41 Six, - - 1 - 3 1 4 2 1 10 - 22 Seven, _ _ _ 1 2 - 1 - 6 1 11 Eight, - - - - - 1 - 1 - 2 Tot lis. 1 9 19 22 57 60 60 55 40 62 > 1 3891 1 Of this number only two families received aid to the amount of $15 or over, and the largest amount of aid paid was $18 a week in one case. Table L. — Number of Families of Irresponsible Fathers which received Aid, classified by Amounts of Aid and Number of Dependent Children in Families. Number OF Families RECEIVING SpECIFIBD AMOUNTS OF Aid per Week. Number of Dependent $2 $3 $4 $5 $6 $7 $8 $9 Children Less but but but but but but but but $10 Not 3tat»d. IN Families . than less less less less less less less Iws Total. $2. than than than than than than than than over. $3. $4. $5. $6. $7. $8. $9. $10. One, . 6 13 15 11 8 7 1 60 Two, . 1 11 18 23 31 42 21 10 1 3 2 163 Three, . 1 3 12 14 21 22 21 19 10 g 1 132 Four, . - - 3 6 7 8 15 11 6 15 2 73 Five, . - - 2 I 3 6 3 8 1 7 31 Six, - - - 2 4 1 2 1 4 1 15 Seven, . - - - _ _ _ 1 1 Eight, . - - _ _ _ _ _ _ 1 _ 1 Nine, . - - _ _ 1 _ _ _ _ _ 1 Not stated. - 1 - - - - - - - - 1 Totals, 2 20 48 61 78 86 68 51 19 39" 6 478' ' The largest amount of aid paid to any family considered in this table was $13 a week in one case. 1918.] SENATE — No. 244. 127 1 I 1:? h!° » « G W Q o> ■t?^ i ■cJ bx ^ e ^ t^ 1-1 1 "^ •fe. ^ fj '1 00 -a HrH| I I I I I IMli-HM »Oi-<"* I I I I I I I I I I 1 1 I wus I i-H I WOO-^WOOO a t- «o «o eo -<*• I I I 1 CCfHCC I OCO OcoMN«oocc 1 1 .-ti-t 1 I cOTtti-t tec I ^^ I CO 1 I I »Ht- . p,p, . . . o o ,- f-* a o a fi o J3 *^ S a •" . I |g I gS - ^i I ^^^ g p, . . • . ■ . §•911 . I I t. „ 5 ea S Q « s g 3 = 3 'S g, •a 9,2^ S " .« -a S M rt^ a 9 » S f* 2 fl S o" g .'g 9 » m a OiS'S a S!> 128 SOCIAL INSURANCE. [Jan. s g *- .3 1 go § I Si "S -o "1 ^ s ^ i "tS CO ^ o ^ 3 « a pin •« € o^ S *3^l |lMWi|(M| r I l«(N 0> $1,000 but less than $1,100. (a^i>^t-c.i>. 1 1 eci-i 1 ^w in CO $900 but less than $1,000. 1 1 1 1 1 1 1 1 1 1 1 1 1 1 ' $800 but less than $900. 1 1 1 1 1 1 1 1 1 1 1 1 1 ^ iH $700 but less than $800. I 1 1 1 1 1 1 1 1 1 1 1 1 1 ' $600 but less than $700. >- ? 'S- S K js> ^_ 1 5-S ts ^ 1 'S Ci *o S 5 ^ ^4 aaoo-^toco-^uscqc^eQccNostoi-xooobcoegooo eoeoec»-Hi-Hi-<»H| I |iH| |cq.-iic3-tJ „j [„ „j „ M rt « S-J^-S 9 £Q Q> 33 3) (D^_£ 55 aj— 'T'^'^ m oa m m m '-' pj'^ to m m m 03 m to «Jh J3^,J3 o^ o^'" m S eS 2 m ^ - S I SI ft o © a s Q .£ ^ H lis « 3 CO I 'Is S^ o S 'E - » ^ .a .2 S g •" J3 o •3 ■» « 50o 130 SOCIAL INSURANCE. [Jan. & .^ s o s e I- ^ ^ Pi e ■ 3 lis <-( ec » a> »o Oi «i oo "* OS -^ob M ^«3 1 ar lO ^ CD ■* (N <» ■* i>- 00 00 !-< lO i-H Pi< U3 eo o> eq M ao •-< 00 u3 1^ ^ o 04 ws ocosi- M o OHO o i> 00 1* to t^ Oi ^ r- M i-(oe •OO^^^oid>eO'-iCOOOS5>OTtiiOOTO C4 ^ O CO Tf CO « ^ (M N t^ ^Oi ^ O !>• Tp W O Cq" ^ O ^ eo eo O M «0 U5 O 00 M TlJ" U5 ^t«^ eo 04eoeocMooe4<-)co^-o^•*Hoo^-teo■^ce^ol ^^co w^eoocoeoiHCqi-ieo *^ «-» ^ eocot-fiHeq o» s _-ooo OOOQ "•fl n ci d a fl n c9 d ^ cJ cd c3 ",£] +3 4J 4J .tJ .4^ ^ _ _ _ ust-o g^«* «••••»«» a a d d MM. 0) tfl *3 3 B S 9 a 9 9 : 3ss; OO OO ^ +J +3 .fS +» ^J -tJ +» ^ ,S'*a .^s^ ■^Jl■^a ^ ^r^ S if^OOO^OOO^ td — ooooQowa^ ~ ;gOr-ICqC0^U3t>O C* •» 4» «• W •»«»«» «V M «» ► TJ S 5 ■°. -o 8 0) S I S .2 M n » d •I . •g j= a a u ■a '3 5 -^ g| ^ 1-5 i s s g ■2 '2 - a » I 5 lO 'g eo O M FM fl O -. « « S 1918.] SENATE — No. 244. 131 lis ^ -? s i o rf V "v « ^ S ^ ° s ^ US i CO e o ^ ^ ^ e1 I II ■a ** s as ■a "j;sgSRSss§a;«sssg3gaigs!g2"»s"sss i-^Sg Q o b |THW^|00^^Mi 1^1 1^1 I I i^^^^|>H|rt| I I I llq^coco-^coeQ |THi-)i-tiHeo incoe^iOi-t \ ci i I I I I IM a'4 ■a «l . . . . Pi . Pi ra . . fl Pi fl - . «- . .'^ • * * s ■ .•a i III _ (D CO _ 0* oo u «.3 M «> ^-h >^+J mfs 2^' ■ a) s cJ-o «2 , .^ t. . in . ^. d V h o sa*al .SJ 2 s a 3 s|| &I iJ S s s I a § a s g-s^i ■sits S'3«o£So.a8 &i| § g I'S g|5 Ibl^li .-♦^ o Ma^ 5 o K S S- as ■n o^ Co Ui go n n ^H^^q^ 1,^ (OOi-Hl^-M lOkOtNcOOa -^-i^iOO^ ^ CO -^ -^ OS '4< ooco<^)0^• t I T-i,-l II II ^« I cccg 1 1 I CO I i-H I CO H^ I I I I »0(N I ^^ I (Mi-< I N 1 "*i-l I -^tM CO i-H 00 C4 t« 04 1-l^«CO0D00 I -^IHiOMCCi-H CCOO-^CO-* w t>- (O ^H ic ^H asTtfMoat— 1 ■* I I I ' 0>— I do g^S= n u 00 O i-HMMM eo iM CO ^ o^-i^* ■*IHTHt^Tt^lOO>Tt^^-^-^^-OJ I W.-I I OO^^C41i-1 j i-((M»-liOCiaOiHrtr. I -H I I I I I I I I I ^ I I I Ir-l|-«t-|cq,-Hl»-ll I |,-l,-((Ni-H|9?|rHi- I I I I I I I I I I I I I I I t I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I r I 1 I I 1 I I I I 1 1 I I I I I I I I I I 1 ^ I t I I I t I 1 I 1 I I 1 1 I N I 1-1 *-( 1-103 I Nt I 1^1 I >H I I I I I I ^ I «a I —tco I^Wtl I I^WMl^-Ml 1 l^»ll IM I I I I 1 I I I I 1 I I I I I 1 -H I «» I '^'- SIsll . (0 . tn CflrT^ .-a 8 3.S s B S -2 3 M £ - - , 2 " a "Ss «i3 G ore's ■ " ■ 'mSSS g.-g o MI'S 1 ■S 2 .a •y J •S V E3 n ■A 01 11 ^ is s m 1 1 00 i _i:l •| 1 ■s a ■a ti Ti o o s 14 o 134 SOCIAL INSURANCE. [Jan. a o O 1 s ^ S I Pi m 3 ■* « « « 100 eg ■* t;^ <» 3 o »-l E-i %i i-i«o-*i-t«e-o> I «seo s !zi| BQ e « •1 S'Ss 1 1 ^ 1 ^ 1 1 ^^(M at *H OS f* •» o 000 less an 100. COCQ-*»t 1 « f-( CQ i-t »0 1-1 C4 »Fs s eSdg , 1 S-"* rto a^5j£ .Q <• 01 p s^Ss III '^ 1 iH K S.'*^'J=] A ■< <»pj*3» K ^ & gJgg Ill 1 fa o •» 3-**«9- I .a m p o gigg 1 1 I 1 1 1 t I 1 ^ N a »^:gR » " fl ^ -T) i ^ 8 Printing ■ Railroad Retail cle Rubber f Stationar Teamster Textile w Professio] Miscellani Not state c8 3 1918.] SENATE — No. 244. 135 Table S. — Number of Irresponsible Fathers who were Insured, classified by Amounts of Insurance and Occupations of Fathers. [Note. — Of the 478 irresponsible fathers, whose families became dependent on account of the .irresponsibility of the father, 48, or 10 per cent., were known to be carrying insurance^ but in 34 cases the amount of the insurance was not stated.] OCOnPATZOHB OF FaTHEBS AT TiuE OF Death.' AUOTTNTS OF InSUBANOE.^ $200 but less than $300. but than $400. $400 but less than $500. $500 but less than $600. $600 but than $700.2 $1,000 but less than $1,100. $1,100 and over. Not stated. Total. Bakers Barbers Boot and shoe workers, Brewery workers, Building trades^ . Bricklayers, masons and plasterers. Painters, decorators and paper- hangers, Other building trades. Government employees. Laborers, .... Longshoremen, . Metal trades. Machinists, Other metal workers, Kmlroad employees, . Retail clerks. Stationary engineers and fire- men, Teamsters, chauffeurs, drivers and stablemen. Textile workers, . Professional and self-employed, Miscellaneous, Not stated Totals, 3! 34 48 ' Certain occupations which appear in the classification of occupations in Table Q were not represented in the data for irresponsible fathers, and have therefore been omitted. 2 None of the policies were for a less amount than $200, and none were for amounts of $700 or over but less than $1,000. » Of this number, 1 was for $1,300 but less than $1,400, and 2 were for $2,000 or over. 136 SOCIAL INSURANCE. [Jan. Table T. — Number of Dependent Families of Deceased Fathers, One or More Members of which Families were Insured, classified by Character of Insurance and Numbers of Members covered.^ [Note. — Of the 2,649 families which became dependent on account of the death of the father, 1,802, or 68 per cent., carried insurance on one or more members of the family.] NuMBBK OF Insured Members in Families.' Classification of In- i "i SUBANCE AOENOIES. s 1 1 ' i o H ^ 1 6 1 i 1 .j:^ M a 1 Insuraiice companies, . rs ISO »« ne 18i 109 88 SI n 7- ■JS 1,U8 MetropoUtan Life Insur- ance Company, 36 73 126 98 86 55 28 18 6 5 25 556 .ITohn Hancock Life Insur- ance Company, I'rudential Life Insurance 16 39 108 78 51 42 28 8 5 1 14 390 Company, 17 16 49 40 22 9 8 4 1 1 5 172 Otheir insurance compa- nies 4 2 9 10 5 3 4 1 - - 2 40 Fraternal orders, . m - S i S _ .- « SI Foresters, 2 3 - 2 1 - 1 - - - - 1 8 Other fraternal orders, 17 - 1 3 _ 1 _ _ _ _ 1 23 Local reUef associations. 3 1 3 „ 1 1 _ _ _ 9 More than one agency. 1 14 38 32 30 18 18 5 7 8 9 180 Not stated 39 28 68 62 49 28 11 14 5 5 115 424 Totals, 136 173 404 324 243 158 98 SO 24 20 172 1,802 * Insured fathers were not included. a All ordere of Foresters were grouped together, because in many instances the original records failed to state definitely which of the several orders was the insuring agency. 1918.] SENATE — No. 244. 137 Table U. — Number of Dependent Families of Incapacitated Fathers, One or More Members of which Families were Insured, classified by Char- acter of Insurance and Numbers of Members covered.^ Note. — Of the 389 families which became dependent on account of the death of the father, 228, or 58.6 per cent., carried insurance on one or more members of the family.] Number of Insured Members in Families. Classification of In- suKANOB Agencies. 6 O H H 1 1 i d % i Z 1 1 1 1 Insurance companies, . Metropolitan Lite Insur- ance Company, John Hancock Life Insiir- ance Company, Prudential Life Insurance Company, Other insurance compa- nies, .... Fraternal orders, . . Foresters, 2 Other fraternal orders. Local rehef associations, More than one agency. Not stated. 17 8 5 4 1 1 3 9 2 1 1 4 IB 10 7 2 8 se 21 10 5 I 1 1 6 1 22 12 8 2 1 1 9 6 16 7 7 2 / 1 4 6 9 3 5 1 1 1 S 3 1 1 2 1 i 2 1 1 1 2 1 S 1 2 1 2 21 76- 48 17 2 8 2 4 1 26 52 Totals, 1 .. . 21 17 27 45 38 27 10 8 7 1 27 228 — — 1 ' Insured fathers were not included, except where their insurance was carried by other mem- bers of family or relatives. 2 All orders of Foresters were grouped together, because in many instances the original records failed to state definitely which of the several orders was the insuring agency. 138 SOCIAL INSURANCE. [Jan. Table V. — Number of Dependent Families of Irresponsible Fathers, One or Mare Members of which Families were Insured, classified by Char- acter of Insurance and Numbers of Members covered.^ [Note. — Of the 478 families which became dependent on account of the death of the father, 281, or 58.8 per cent., carried insurance on one or more members of the family.] Number of Insitbed Membees in Families.' Classipioation op In- stjBANOB Agencies. § O 1 1 3 £ 1 i i 1 i 1 i B Insurance companies, . Metropolitan Life Insur- ance Company, John Hancock Life Instir- ance Company, Prudential Life Insurance Company, Other insmrance compa- nies, .... Fraternal orders, . Foresters, 2 Other fraternal orders. Local relief associations. More than one agency. Not stated u 9 2 3 1 1 1 4 16 6 7 . 3 2 9 49 26 19 2 2 1 1 8 14 23 13 5 1 2 4 20 IS 10 5 3 1 4 so 8 8 4 1 3 B 2 1 S 2 2 1 1 1 1 1 1 S 3 2 1 1 8 2 5 1 3 17 m 91 64 21 21 74 Totals, 20 27 72 68 23 24 3 7 2 7 28 281 1 * Insured fathers were included when their insurance was carried by the family in the father's absence. 2 All orders of Foresters were grouped together, because in many instances the original records failed to state definitely which of the several orders was the insuring agency. 1918.] SENATE — No. 244. 139 ^& i rS? ji •^ -& « S fts ^ i ^ -^ h § ^ o 1 1 CO M (11 e ■3 o i^ 1 ^ 1 siiiss's i ^ 1^ |1 «ojgco 1 i-t 1 -^ s ^1 1 t» O CO CO to i-i « 1-t s^ i-< Cq ■ O 1-1 " «» t^i . 1 t o^®t>»«;-4eo (D tHi-ti-l B> g H S|S S: PS 1 i H s-".a . T-HO-^OlOlOfHlH iH h oStS- <^.S 9 1 cooo'*'»eo 1 -^ © d43 ® *o 1 ^Mto 3 IS its !■ ■S S-S »-ioocow3r-i-ii-i« A rH'*^ SO o e js Iz; B S ■s si W«^M^(MNOS lA -< m C3 !^^»0 tH OQ o ^o ID ,Str- " Si i-( CO £>• oa t~ 1 1 U5 N ,^tO m d GQ E4 ■*^ S-*^ p:] S-^^-^S Oi so O O DO N CO "3 CO g 3^16 COCnu^ s a § MS S 9-2 ©as,"!; I>- O !-< CO to (N 1 oo D- ^S-*co (0 o£to CO S J3 m c4 03 -tj ^ -p CSlOOCOOOtN ! O i-HrfHCKM '-' o^«o CO s Js s^i CO »o eq Tfi (M iH 1 CO M m i-Ht-O^ 5 to H -*) Ph f» 0»-<(M pqco fii •TH*9ft»fl»«» ^ *!« fl a fl o a cd eg cd ci .^^^^^ ^ . I giJIIlli 1 &i ri oioomo o 1 P «» «» WCA W» W <1 140 SOCIAL INSURANCE. [Jan. CO 53 IB » ^ I .2^ ^ k ■* t- o ^ 5 i ^ S3 w s J » ^ a HO « © ■§ i t I J I sa. • M o 1 H >q b* < & H ■a :5i rtO £S ■2 g-S cm ■2 g-S g^:gS g^|g 50 I /^ CO "* O M !» rH I O I I *H I I I [ I I iieqcM I i-H I csi \ me^-^t I I 500C4 I I I »-ir*o I M I I ^ y-l^Ui I ^ I I W 1 U3O0C4 I I I N I «MOCO I I I I H ^ *^fl fl fl fl ta ^ a ta :2 -^ -^^ •♦^ ■*^ tT 03 ffi 03 Kl JDt- ^ Iplllll 3 ,1918.] SENATE — No. 244. 141 ^ I I <» GO 1 CD I 13 OS 00 M iH W 1-1 IM lO t-i -S T^^CO oo o »-Hi-H P4 H |1 1 U3tH 1 1 1 1 1 to zf CO SO 1 1 1 "H lA M&^ 142 SOCIAL INSURANCE. [Jan. Appendix B REPORT ON DISPENSARY CLINICS IN MASSACHUSETTS, PARTICULARLY IN BOSTON. Prepared for the Massachusetts Special Commission on Social Insurance by Michael M. Davis, Jr., Ph.D., Director of the Boston Dispensary. Boston includes some of ' the oldest and best-known medical institutions in the United States. Among these the dispensaries and the out-patient departments of hospitals have developed as far as in any other city in the country. A dispensary or out- patient department may be defined as a medical institution which provides medical care for people whose illness is not such as to confine them to bed, i.e., for ambulatory cases, so called. There is no difference between a dispensary and an out-patient department, except that the latter term is usually employed when the clinics are part of a hospital organization, while the term "dispensary" suggests clinics which do the same work but which are separate from any hospital. The Social Insurance Commission has been interested to ascertain the extent to which dispensary service has grown in Boston and elsewhere' in the Commonwealth; the proportion of the population which dispensaries are reaching; the social and economic classes reached; and the kinds of medical service which are provided. Dispensaries and out-patient departments of the hospitals are generally philanthropic institutions. They usually charge small fees; for instance, 25 or 10 cents per visit, and a similar amount for medicines, etc. These fees are generally reinitted in whole or in part when the circumstances of the patient appear to render it necessary. With the assistance of the State Board of Charity, to which all incorporated charitable institutions must report annually, the list of all dispensaries and out-patient departments was 1918.] _ SENATE — No. 244. 143 secured, and the general statistics of their work ascertained. Table I. shows a list of 22 dispensaries ^ and out-patient depart- ments in Boston, and the total attendance, or number of "visits" made by patients to the clinics, also the number of new patients received during the most recent year for which statistics are available; this was usually 1916. It will be observed that the total annual attendance at these dispensaries was over 800,000, and that the number of new patients was over 200,000. To ascertain • the number of dif- ferent individuals we must bear in mind that there are a certain number of persons who are treated at more than one dispensary. Investigations published in "The Modern Hospital" of 1916 (Vol. VII., p. 359) indicate that this overlapping is small, not over 10 per cent, and probably not over 5 per cent. On the other hand, the number of "new patients" at the dispensaries during a year does not equal the number of different individuals during the same period, since many old patients who were treated during a previous year keep on coming. A total attendance of 822,000 probably represents about 300,000 different persons. Deducting 10 per cent, for overlapping we have 270,000. Not all of these are from the city of Boston, but the great majority are. Certain of the dispensaries receive patients from Boston only; some, like the Massachusetts General Hospital and the Children's Hospital, receive a considerable proportion from out- side the city. Only a few of the annual reports of the institu- tions state the proportions exactly, but it is very probable that fully three-quarters of the attendance is from within the city limits. Three-quarters of 270,000 is 202,500. It is safe to say that 200,000 residents of Boston receive treatment annually" at the dispensaries of the city. This is one-quarter of the total population. It must not be inferred that this vast number of persons received all of their medical service through these dispensaries. Many of them received part of their medical service from a private physician, and came to the dispensaries for special service only. All of the general dispensaries have departments representing the chief special branches of medicine and surgery. The usual departments include general medical; children's medical; surgical; eye; nose, throat and ear; skin; gyneco- logical; genito-urinary; orthopedic; neurological; and dental. 1 The list as thus reported is incomplete, omitting certain out-patient departments, and several small dispensaries. The figures given are therefore less than the full facts would show. 144 SOCIAL INSURANCE. [Jan. More than half of the patients of the dispensaries come for treatment in the specialties, that is, for care other than a general practitioner would afford. The three departments which correspond more or less to the field covered by the general practitioner are the medical (adult and children's) and the general surgical. At the out-patient department of the Boston City Hospital 68 per cent, of the new patients come to these three clinics, and 32 per cent, come to clinics dealing with specialties. At the Massachusetts General Hospital out-patient department, 583^ per cent, of the new patients come to the three general clinics, and 413^ per cent, to the specialties. At the Boston Dispensary the proportion is reversed, 39 per cent, coming to the general and 61 per cent, to the special clinics. The average for these three largest institu- tions is 55 per cent, of new patients in the three general clinics, and forty-five per cent, in the specialties. But a considerable proportion of patients (certainly over 10 per cent, and probably 25 per cent.) in the medical, children's and surgical clinics come to see a specialist. We may say with assurance that more than half of all the patients at dispensaries come to secure service such as requires a specialist rather than a general medical practitioner. In view of the high cost of specialist service at private office rates, this proportion is significant. There are, in fact, large numbers of families who can and do employ a general practitioner for ordinary ailments, but who cannot afford to pay for the work of an oculist, or a throat specialist, or a specialist in the diseases of children, etc. Also it is a matter of common knowledge to all hospital administrators 'that a -certain proportion of dispensary patients are referred by doctors, mostly general practitioners, who wish their patients to have specialist service which the patient cannot pay. All the dispensaries on the list aim to reject patients who can afford to pay a private physician for the care they need. The accurate enforcement of this policy is not always easy, for obvious reasons. Investigations have indicated, however, that the pro- portion of applicants for treatment at the Boston Dispensary and the out-patient department of the Massachusetts General Hospital who could pay for the medical service which they need is very small, less than 5 per cent. (See Annual Report, Boston Dispensary, 1915, page 46.) From what social classes does this army of 200,000 patients come? The great bulk are wage earners or their dependents. 1918.] SENATE — No. 244. 145 In Table II. is shown the family incomes, taken consecutively, of 1,196 families of the patients in the Boston Dispensary in September, 1917, and of 192 families of patients in the out- patient department of the Massachusetts General Hospital in November. Table III. shows the incomes of 1,457 individual wage earners, at the Boston Dispensary, taken during August, 1917. The family incomes, of course, include supplementary earnings of adults or children other than the chief wage earner. It will be observed in Table II. that the Massachusetts General Hospital figures agree quite closely with those from the Boston Dispensary, although the number of cases from the Massa- chusetts General Hospital is rather small on which to base any conclusions. From these tables taken together we may see that about 40 per cent, of the families of these dispensary patients are earning less than $15 a week, about 45 per cent, earn between $15 and $20, and 20 to 15 per cent, over $20 a week. In other words, a little less than half of these families have an income of $800 or less a year, and about the same number have incomes between $800 and $1,000 a year.i A highly significant figure appears in Table II., viz., the number of cases known to be receiving material aid, i.e., money, food, clothing, fuel, etc., at the time whfen they were dispensary patients. It is to be noticed that the proportion of families thus aided by charity was less than 3 per cent, among 1,196 Boston Dispensary families.^ It is safe to say that not over 5 per cent, of the patients at the dispensaries are usually in receipt of material aid from charitable agencies. In other words, the great bulk of the families whose members are cared for by the dispensaries of Boston are able to meet the ordinary expenses of maintaining a family during health, but they cannot meet the expenses of illness and pay the cost of 'medical service in addi- tion. Table IV. (a) and Table IV. (6) show the size of family among the same group of patients of the Massachusetts General Hos- ' These estimates of income, based on usual weekly earnings, are probably conservative, as most working people have periods of unemployment which, even during the present prosperous times, would amount to something during the year. The figures, moreover, correspond quite closely to the general levels of wage earners' incomes, which the reports of our State Bureau of Statistics show to prevail in this community. ' Reference is made later to a special intensive study of a number of families made by the social service departments of the Massachusetts General Hospital, Boston City Hospital, Psychopathic Hospital and Boston Dispensary. It was found that only 49 out of 159 famiUes, or less than 30 per cent., were in receipt o^ material aid, although social service department cases are usually those who present some family problem, or distress, other than medical need. 146 SOCIAL INSURANCE. . [Jan. pital and the Boston Dispensary. It appears that a majority of families have three children or more; that the proportion of large families is not, however, unduly great; that, in fact, the size and constitution of families is not very different from that which would be found in the community as a whole. Previous to the war-time regime of abnormally high prices, an income of $800 a year for a family of average size in Boston was estimated by several careful students to be barely sufficient for the minimum physical necessities, and to give no margin for the emergency of illness. An income of $1,000 a year, for a family of five or six, gave only a very slight margin. Thus even before the war families receiving such incomes as these dispensary patients possess could but just support themselves during health, but could not bear the burden of illness without either deprivation of food or other necessities or resources to charity. At the present time the above estimates are too low, for wages have on the average risen m.uch less than the cost of living. The incomes of these dispensary patients are not lower than those shown by our State Bureau to prevail among many wage-earning groups. They can often pay for medical service in an emergency, but out of an income of $1,000' or $2,000 a year a family of five or six persons cannot meet the expense of specialist service, nor of any long-continued illness. The question has been raised whether, under the present system, the patient frequently delays in getting medical treat- ment long after the onset of his disease. Data were secured on this point from 1,529 patients at the Boston Dispensary, and 197 at the out-patient department of the Massachusetts General Hospital, a total of 1,726. The details are shown in Tables V. (a) and Table V. (6). Out of 1,726, 1,236 had had no medical care previous to coming to the clinic, and 435 of these, or 35 per cent., had been suffering from their ailment for three months or more before seeking the clinic care; 163 additional cases, or 13 per cent, out of the same 1,236, had delayed from one to three months. Out of the whole 1,726 cases, 350 had waited from a week to a month, while 430 persons had gone to the clinic within a week from the time they felt their illness. These figures can be better understood when delay in securing treatment is tabulated in connection with particular diseases. This is done in Table V. (a) for 1,529 Boston Dispensary cases. An examination of this table shows what would be expected, — that where diseases are such as cause much pain or discomfort 1918.] SENATE — No. 244. 147 in their early" stages — such as minor surgical lesions, cuts, burns, etc., or irritations of the skin — treatment is sought pretty promptly. On the other hand, with diseases that cause less trouble to the patient in the beginning, but which are often much more serious, there is frequently more delay. Thus 15 out of 29 patients with tuberculosis were conscious of illness over three months before they sought any kind of treatment, and 7 waited a whole year; 15 out of 37 cases of syphilis waited more than three months, which is past the period when the disease can be most effectively dealt with; 40 out of 69 cases of disorders of the circulatory system (mostly heart diseases) and 10 out of 21 cases of kidney disease waited over three months. Of the minor diseases of the ear, nose and throat, not requir- ing operation, 48 out of 75 cases waited less than one month, while out of 152 more serious cases, requiring surgical operation, only 43 cases came within a month, and 98 cases waited over three months. The same contrast appears in " general surgery " between the non-operative and usually minor cases and the operative cases, which are generally more serious (see Table V. (a) ). The longer period of waiting before medical treatment is secured does not always mean less chance of cure. In some cases it does mean that, and in most cases it means greater difficulty and expense of cure or of effective treatment, as well as a period during which the comfort and working efficiency of the suffered is diminished more or less greatly. The same tables also show the proportion of patients who had some medical care previous to coming to the clinics, and whether this care was secured from a private doctor or from another medical institution (usually a hospital). It will be observed that 331 cases had previously been to a private doctor. The usual reason given for leaving him was that they "had no more money to pay him." A considerable number of cases are referred to the clinics by the doctors for consultation or for care by a specialist for which the patient could not pay at private rates. The fact that of these 1,726 cases only 339 had had a private doctor, whereas 435 persons had waited three months or more before getting any medical treatment, suggests that private medical practice is not sought by a large proportion of people because they feel they cannot afEord it. It also indicates there are many persons who either do not know of dispensaries, or 148 SOCIAL INSURANCE. [Jan. who do not wish to accept medical charity. Under the best conditions people will often delay in going to a doctor, even if a doctor is free. The figures regarding delayed treatment must be interpreted with this caution in mind. The social service departments of the four institutions above mentioned rendered reports of 159 cases which had been in- dividually studied. Among the points taken up was the extent of any form of insurance in these families. It was found that sickness insurance was infrequent. Only 23 out of 159 families carried any sickness insurance; 124 stated that they had none; in 12 cases no data on this point were secured. Life insurance was fairly frequent, 60 families carrying some insurance on one or more members, 78 carrying none, and 20 furnishing no information on this matter. This "life insurance" is usually industrial insurance on the weekly payment plan, providing small amounts on the death of the insured person. The majority of the 60 cases pay 50 cents a week or more for this insurance. A comparison of the figures secured in this study may be made with the information gathered in California by the social in- surance commission of that State in 1916, and published in their report during the early part of 1917. "Among 2,587 patients applying at dispensary clinics in San Francisco, only 53 were dependent upon charity, public or private, for their support" (page 43 of report). In addition there were 137 cases of unem- ployment where dependency was imminent, making a total of 190 cases, or 7 per cent., in which the "application for free treatment at the clinics in San Francisco could be attributed to the fact of dependency or unemployment" (page 44). In 42 per cent, of the 2,587 San Francisco cases the family income was $14 or under a week, which compares closely with the 36 per cent, found among the Boston Dispensary patients, and 43 per cent, among the Massachusetts General Hospital cases. The studies in Boston and San Francisco, the two extremes of the continent, are alike in showing that a large number of seK- supporting wage earners of small incomes, not otherwise de- pendent, are seeking medical assistance at dispensary clinics. In the city of Boston we found that a quarter of the popula- tion receive care at dispensary clinics annually. A marked contrast appears between Boston and the remainder of the Commonwealth. From data furnished by the State Board of Charity, which is required by law to receive reports from all incorporated charitable organizations, we find that in Massa- 1918.] SENATE — No. 244, 149 chusetts, outside of Boston, there are only 30 dispensaries and out-patient departments. The total number of visits paid by patients to these 30 dispensaries and out-patient departments was 138,000 for the last year during which reports were available (usually 1916). The list of institutions is given in Table VI. The number of new patients reported was 32,000, and the prob- able total number of different individuals treated was between 50,000 and 60,000. Boston has one-fifth the population of the Commonwealth, but between three and four times as many dispensary patients as all the other cities and towns ■ in the Commonwealth put together. This is true in spite of the fact that Boston has more physicians iji proportion to its population than the rest of the State. The fact that all or nearly all of the tuberculosis dispensaries are omitted from the list in Table VI. (as well as in Table I.) would not substantially' affect the comparison between Boston and the rest of the Commonwealth. Do these facts mean that Boston is oversupplied with facilities for charitable medical care, or does it mean that the remainder of the Commonwealth is undersupplied? The statistics gathered do not furnish an answer to this inquiry. There can be little doubt that many communities in Massachusetts contain large numbers of wage earners whose incomes are no higher than those found among dispensary patients in Boston. The question may at least be raised whether no need exists, in such com- munities, for some system or organized medical care such as the dispensaries of the metropolis in a measure provide? The organization of dispensaries as found in Boston would of necessity have to be adapted to the conditions in smaller com- munities. In a large city specialists in all the different branches of medicine are usually found, but they are relatively much fewer in smaller places. The large dispensary, particularly if attached to an important hospital, offers medical advantage to the physicians on its staff in providing facilities for diagnosis and consultation which a small dispensary cannot offer. Con- nection with a medical school is also of value to a physician, and is not possible except in a city which has one or more medical colleges. For all these reasons it would be much more difficult and .often impossible to secure in small communities anything like the amount of volunteer medical service which is found in the dispensaries of Boston. It may, indeed, be questioned whether the custom of depending upon volunteer medical service in dispensaries in Boston and in other large cities has not reached 150 SOCIAL INSURANCE. [Jan. a point at which the system threatens to break down by its own weight. In any case there can be little doubt that expansion of dispensaries in the smaller communities of the Commonwealth must be based upon a system of remunerated medical services, and that such remuneration is necessary both in justice to the medical profession and in order to have sufficient and efficient service in the clinics. One of the disadvantages of the present system in the dispensaries of Boston is the fact that almost all the clinics are held during working hours, so that wage earners coming to the dispensaries lose time and money. So far as dispensary service is to be for the benefit of employed persons, it should include, in Boston and elsewhere in the Commonwealth, a reasonable proportion of clinics held in the late afternoon or evening. SUMMAEY. Twenty-two dispensaries in Boston treat 200,000 persons annually, or one-quarter of the population of the city. In all the remainder of the Commonwealth there are only about 30 dispensaries, receiving altogether only 50,000 to 60,000 patients a year. Facts gathered concerning certain groups of dispensary patients in Boston indicate that the bulk are from self-support- ing families with incomes similar to those possessed by the majority of wage-earning families in general; and that these families, while able to meet their ordinary expenses, cannot provide for the emergency of sickness nor pay sufficient for the medical service which they require to secure at private phy- sicians' rates. Delay in securing needed medical treatment, after the onset of disease, is frequent, especially in diseases which begin insidiously, even when they are serious. Protection to the wage earner or his family by means of sickness insurance is infrequent. The present dispensary system, while providing greatly needed treatment both in general medicine and surgery and in the specialties, has the disadvantages of depending upon volunteer medical service, and of being usually inaccessible to wage earners except during working hours. 1918.] SENATE — No. 244. 151 Table I. — Dispensaries and Out-patient Departments in Boston. [In certain cases which are marked with an * the reports of the institutions as furnished to the State Board of Charity did not contain the niunber of visits, and in certain other instances they did not contain the number of new patients. Where either figure was given the other has been estimated according to the rule that the number qS. visits is usually not less than three times the number of new patients.] Name of Institution. Total Visits. Total New Patients. Berkeley Infirmary, . 5,075 782 Boston City Hospital, 148,399 39,351 Boston Dispensary, ... 118,918 24,505 Boston Lying-in Hospital, 7,388 1,632 Carney Hospital, 48,111 18,965 Children's Hospital, . 44,405 9,283 Denison House, . . . 4,848* 1,616 Dispensary for Women, . . . • 10,111 1,093 Dorchester Relief Society, ... 1,0001 3001 Forsyth Dental Infirmary, 29,186 17,060 Jamaica Plain Dispensary, 1,326* 442 Lincoln House Association, 6,778* 1,926 Massachusetts Charitable Eye and Ear Infirmary, 76,017 30,698 Massachusetts General Hospital, 201,375 31,061 Massachusetts Homoeopathic Hospital, . 44,094 12,745 Maverick Dispensary, 8,301 2,052 New England Hospital for Women and Children, 6,012* 2,004 Peter Bent Brigham Hospital, . . . • 36,523 8,536 St. Elizabeth's Hospital, . 8,713 2,936 St. Stephen's Settlement, Salvation Army (Rescue Home), 300* 100 Woman's Home Missionary Society (Hull Street Dispensary), 16,643 5,548* Totals, 822,523 212,635 1 Estimated. 152 SOCIAL INSURANCE. [Jan. Table II. - Incomes of Families, Boston Dispensary and Massachusetts General Hospital Patients, 1917. Income Group. Boston Dispensary. EHAL Hospital. Number. Percentage. Number. Percentage. JIO, ... $10.50-114, . . . . . $14.50-820, $20.50-$26, $25.50 and over, 169 275 547 89 81 14.0 22.0 45.0 7.4 6.7 45 39 72 20 7 23.0 20.0 37.5 11.0 4.0 Not aided, . . . Receiving material aid, . 1,161 35 2.9 91 4.5 Totals 1,196 100.0 192 100.0 1 Income not stated. Table III. — Boston Dispensary Patients, October, 1917, Wage Group. Wage Earners' Incomes. Number. Percentage. $10, ... ... $10.50-$14, . . $14.50-$20, . ... . . $20.50-$25, ... . .... $25.50 and over, . . . . ... 240 430 697 77 13 16.5 29.5 47.8 5.3 .9 Totals, . . .... 1,457 100.0 1918.] SENATE — No. 244. 153 1 i S§§||§S;SSS3 s 1 CO 1 . 1 1 IN|i-<-MNC<»
    -*w 1 . — Classification of Boston Family Group b 3S3SSSSSS=° ' « CO i si J-o TjHCC^^C^tO'N-*'-'! 1 K i s 4 r. o -^ 1 i-i IN 1 1 1 1 - s 1 ^"SSSS"""- ' -• at c 1 1 < 1 ii 5 , „- o- 2 3 S 2 g S i . O "O. o im' -x" =o oo o >o o -0 4 154 SOCIAL INSURANCE. [Jan. I 13 OS CO S^J ^^ 73 S 1^ Is o 5 Hi M i S S S S S 3 " CM Single Work- ing Person. t- 03 '^ _ 'I 1 1 1 CO Married Couple, No Chil- dren. eo -^ "* »o cfl 'H CO CO C4 o w o M.t 1 1 I ^ CO lO 1 o ° a 1 1 -^ i-H 1-1 CO 11 o 1 cq ■* i-« ea ( 1 o s" ■=5 o 1 rH N « w ^ 1 00 (M « CX) (N ^ t 1 s o 1 « «-< CO !-< eq CO en . "i^ N 00 e* ■* I I 1 eq o h\i I 1 1 l-H d .-H ^ »o o.S ■*■«*< W CO 1 »-C i-H s S 1 a H 3 S S t § - !l ? ? T - 1 o i li i .^ cJ 5 S S S 3 S S ^ .2 1 1918.] SENATE — No. 244. 155 I •mox s S ^ i CO s§ s g ^ ^ j_, 1 [33M I 00 •JBa^ I J9A0 •OT9X I 1 1 ) (N CO c^ IM 1 I I -. S; "= CO o i o t« ti g •< •eqjnopi s 0^ I ■* •l^nojt I 1 1 w (M -^ eo - 1 1 1 C4 iM ^ 2 i h O* 3t99jVl I 1 ^ co 1 1 ^^ ■* ^ I 1 -H 1 ^ ■SS9T[ JO 3199M I CO 1 C4 t^ <£> CO ko s ^ •JB9^ I J9A0 1 ^ n •luaji I 1 ^ o> CO 1 M N 1 -. I ^ « s s XB o^ sionoH s e« »o CO •eqjnoiv g Of> x eo ■* •qjnoH: I i-H « 00 CO CO CO CO ^ e), 36 48 S5 00 7 00 8 8 SlOO 00 100 00 Benefits begin with eighth day of disability. Employer contributes amount equal to one-halj^ payments by membere. ' Sickness benefits qost the association about $1,500 annually. Logan, Swift & Bngham, Worcester. Women's Mutval Relief Association. [Organized July, 1911.1 38 members, divided into three classes: — (o) Ages 15 to 24, . . 45 15 00 721 SlOO 00 (6) Ages 25 to 39, . ... 50 5 00 721 100 00 (c) Ages 40 to 50, . . . 65 5 00 721 100 00 Benefits begin with seventh day of disability. Employer agrees to contribute not exceeding $200 annually. 1 Days. Eaton, Crane & Pike, PittsfieU. [Reorganized in September, 1911.] 700 members, divided into 2 classes: — (0), ... ■ . . 35 SS 00 8 SlOO 00 (6). 50 7 00 8 100 00 Benefits begin with eighth day of disability. Employer agreed to pay $500 annually during the first three years of the life of the association. Sickness benefits cost the association $2,000 annually. Premiums on Savings Bank Insurance group policy cost, net, about $460 annually. American Hide and Leather Company, Lowell, [Organized June, 1912.] 200 members, divided into two classes: — (o) Persons under 40, . 35 $5 00 9 $100 00 (6) Persons over 40, . . . 60 5 00 9 100 00 Benefits begin with eighth day of disability. Employer contributes 8500 to the treasury of the association annually. Sickness benefits cost the association $550 annually. 1918.] SENATE — No. 244. 173 Norwood Engineering Company, Florence. [Organized July, 1916.] Weekly Dues (Cents). Weekly Sickness Benefit. Maximum Sickness Benefit (Weeks). Death Benefit in Bank Life In- surance. 170 members, only one class, 10 SS 00 $100 00 Employer pays the premium on the Savings Bank Life Insurance group policy. Benefits begin -with eighth day of disability. White & Wyckoff Manufacturing Company, Holyoke. [Organized August, 1916.] 230 members, only one class. 10 S3 00 3100 00 Employer pays the premium on the Savings Bank Life Insurance group policy. Benefits begin with eighth day of disability. Arnold Print Works, North Adams. [Organized May, 1917.1 Weekly Dues. Weekly Sickness Benefit. Max- imum Sickness Benefit. Death Benefit in Savings Bank Life Insurance. 570 members, divided into two classes: — («) ... (6), . . .... 10 20 id 00 10 00 10 10 Amount varies from 1200 to 8500, accord- ing to length of serv- ice with Arnold Print Works. Benefits begin with eighth day of disability. Employer pays the premium on the Savings Bank Life Insurance group policy. Cass & Daley Shoe Company, Salem. [Organized February, 1917.) 500 members, divided into three classes: — (a), .... (6), . . • • • • SS 00 7 50 10 00 Amount varies from JlOO to S500, accord- ing to length of serv- ice with Cass & Daley Shoe Com- pany. 3 Employer pays the premium on the Savings Bank Life Insurance group policy. Benefits begin with eighth day of disability. It is estimated • that there are in Massachusetts at least 750 employers who employ not less than 200 persons; and that there are more than 300 employers who employ not less than 500 persons. 174 . SOCIAL INSURANCE. [Jan. Here is a great army of 300,000 men and women wage earners, a very large percentage of whom have made no provision against the day when there is no pay envelope. Some have deposits in the savings banks; some have shares in the co-operative banks; others, more particularly the foreign-born, are saving through the postal savings plan; and many are saving through Christmas savings clubs. But these several forms of saving are sporadic efforts in the main, and the great need appears to be for systematic saving. I call your attention to chapter 168 of the General Acts of 1915, and suggest that possibly a provision of law similar to that would be the simplest step to take in the direction of accomplish- ing what you have in mind. As to the amount of the appropriation, that would depend entirely upon the number of men whom it was deemed wise to employ. One person could perhaps reach 5,000 wage earners in a year. This is a very rough estimate, and is suggested for your guidance merely. If I can serve you in any way in this connection, please do not hesitate to let me know. Yours very truly, ALICE H. GRADY, Secretary, Trustees' of the General Insurance Gvarardy Fund. 1918.] SENATE — No. 244. 175 Appendix H. PROPOSED LEGISLATION. An Act to extend Voluntary Industrial Group Insurance. Be it enacted, etc., as follows: Section 1. The sum of shall be allowed and paid out of the treasury of the coinmonwealth from the ordinary revenue, to be expended ^^deT the direction of the trustees of the General Insurance Guaranty Fund, for the purpose of further encouraging an4 promoting the organization of mutual benefit associations among thp employees in industrial plants in Massa- chusetts, as is already carried on under the direction of the Massachusetts Savings Bank Life Insurance, in order to afford them an opportunity to insure themselves against sickness and disability at their option. Section 2. The said trustees shall have authority to employ such agents or solicitors as they may deem necessary for the purposes aforesaid, and also such additional clerical assistance as may be necessary from time to time. An Act to provjde Diagnostic Equipivient for Clinics and Dispensaries and to encourage their Extension. Be it enacted, etc., as follows: Section 1, In order to provide facilities for the di^-gnosis and treatment of disease, which irjay not otherwise be available in cities or towns of this commonwealth, the st£|.te department of health may assist, as hereinafter provided, in supplying labora- tory equipment or X-ray equipment for the diagnosis of disease, to be used in connection with dispensaries or with the out- patient departments of hospitals in said cities or towns. Equip- ment shall be furnished only to dispensaries or out-patient departments of hospitals which are conducted by ^ city or town, or to any dispensary or any out-patient department of a hospital with which a city or town contracts for the care of sick persons. 176 SOCIAL INSURANCE. [Jan. Section 2. Said assistance ma,y be furnished in the form of equipment itself, or of money for the purchase of equipment, but shall in the case of no city or town exceed the value of one thousand five hundred dollars, and shall be conditioned upon the provision of at least an equal sum, or of equipment of at least equal value, by the city or town. Section 3. The use of said equipment in the diagnosis of disease shall, under regulations to be established by the city or town, or the board of health thereof, with the state department of health, be available for regularly licensed physicians for the benefit of patients, or for the members of associations or or- ganizations of employers, employees or other persons in the cities or towns where the equipment is located, or in contiguous cities or towns not similarly equipped. Section 4. . The state department of health is hereby em- powered to prescribe necessary rules and regulations, under which said diagnostic equipment shall be used. Section 5. For the purpose of carrying out the provisions of this act there shall be allowed and paid from the treasury of the commonwealth the sum of ten thousand dollars, to be expended under the direction of the state department of health. An Act to provide Free Medical Treatment for School Children. Be it enacted, etc., as follows: Section 1. Such physicians and nurses as may be necessary shall be appointed and maintained for the medical and surgical care and treatment of all school pupils of the commonwealth as hereinafter more particularly provided. Section 2. Under the jurisdiction of this act, such medical and surgical care shall consist of medical diagnosis, and the medical and surgical treatment of the eyes, ears, noses, teeth, throats, lungs, posture and nervous systems of the pupils. Section 3. The operation of this act shall be under the supervision of local boards of health subject to the approval of the state department of health, and shall exclude those pupils therefrom so desig:nated by their parents in writing. Section 4. The expenditures under this act shall be charge- able to and apportioned between the towns, the cities and the commonwealth in such proportions as the general court shall determine. 1918.] SENATE — No. 244. 177 Section 5. All acts or parts of acts inconsistent herewith are hereby repealed. Section 6. This act shall take effect upon its passage. Resolve to establish a Commission to study the Question of a State System op Sickness Insueance foe the Wage Earners op THE Commonwealth. Resolved, That the governor, with the advice and consent of the council, shall appoint a commission of five persons, citizens of the commonwealth, one of whom shall be a representative of labor and one of whom shall be designated as chairman, for the purpose of further investigating and study- ing the question of state health insurance as a measure of relief for the wage earners suffering from sickness and its consequences. The com- mission shall make such further studies and investigations as it may deem necessary as to the health of the wage earners, the conditions under which they labor, the present means of insurance and its availability to the working people of the commonwealth, and also the extent to which illness is responsible for poverty among our wage earners. The commission shall have authority to study systems of governmental sickness insurance abroad, and also to correspond and confer with existing and future state committees and commissions in this country which may be considering the sickness insurance question, with a view to dealing more intelligently with the subject and possibly insuring uniformity in the more important provisions in the drafting of such legislation. The commission shall be provided with suitable quarters in the state' house. It may employ all necessary clerical or other assistance, and may incur such reasonable expense, including traveling expenses, and shall receive such remunera- tion as the governor and council may approve. The commission shall report in print, with drafts of such laws as it may recommend and a compilation of the data and statistics deemed necessary on which to base legislative action, on or before the second Wednesday in January in the year nineteen hundred and twenty, and the powers of the said commission shall terminate on that date. The commission shall be allowed for com- pensation, clerical and other assistance, for travel, stationery and other necessary incidental expenses, such sums as the governor and council may approve, but not exceeding twenty-five thousand dollars. An Act defining "Personal Injury" as used in the Work- men's Compensation Act, so called. Be it enacted, etc., as follows: Section one of chapter seven hundred and fifty-one of the acts of the year nineteen hundred and eleven is hereby amended by adding the following new sentence at the end of said section: — "Personal injury" shall include any injury or damage or harm 178 SOCIAL INSURANCE. [Jan. 1918. or disease or condition, in the causation ox acceleration of which the employment is a material contributing cause, which results in total or partial incapacity for work; and for the purposes of this act the date upon which an employee first loses wages as a result of a personal injury shall be the date from which com- pensation shall be computed, — so that said section as amended shall read as follows : — Section 1. If an employee who has not given notice of his claim of common law rights of action, as provided in Part I, section five, or who has given such notice and has waived the same, receives a personal injury arising out of and in the course of his employment, he shall be paid com- pensation by the association, as hereinafter provided, if his em- ployer is a subscriber at the time of the injury. "Personal injury" shall include any injury or damage or harm or disease or condition, in the causation or acceleration of which the em- ployment is a material contributing cause, which results in total or partial incapacity for work; and for the purposes of this act the date upon which an employee first loses wages as a result of a personal injury shall be the date from which compensation shall be computed. DATE DUE APR^ =Mftaa :;-;!4^?1-ffii "ftW^OAN ;i-^P y J '^''^i-^ ■ 1 1 GAYLOND PRINTCOINU.S.A. Cornell Un iversity Li brary HD7123.M4 1918f ' Report of the Special commission on soci 3 1924 002 406 530 rS- ^''VW