Cornell University Library HD7102.U5O3 1919 Health, health Insurance, old age pensio 3 1924 002 406 977 Cornell University Library 3j 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/cu31924002406977 HEALTH HEALTH INSURANCE OLD AGE PENSIONS RECOMMENDATIONS ^ DISSENTING OPINIONS m. The Ohio Health and Old Ase Iiisuraiij^# Coiinnissioii COLUMBUS FEBRiARY, 1919 MEMBERS OF THE COMMISSION W A JULIAN, T. J. DONNELLy,. M. B. HAMMOND, A. R- WARNER^^*^ D. F. GARLAND, 0. B. chapm^an: ; R. E. LEE, H. R- MENGERT, SecretaJ^' -V ■!■■-■ -■ JOHN A. LAPP, Director of Investigations. HEALTH HEALTH INSURANCE OLD AGE PENSIONS ,■># \t REPORT RECOMMENDATIONS DISSENTING OPINIONS BY The Ohio Health and Old Age Insurance Commission COLUMBUS FEBRUARY, 1919 ""f-f. COLUMBUS. OHIO: THE F. J HEEB PRINTING CO. 1919 Bounds at the St4te Itui4ery. '* i0i f?l |6/is LETTER OF TRANSMITTAL Columbus, Ohio, February i, 1919. To the Members of the Eighty-third General Assembly, State of Ohio. Gentlemen: Pursuant to House Bill No. 461 (Laws of Ohio, 1 91 7, pp. 520 and 521), the Commission authorized therein hereby trans- mits to the Eighty-third General Assembly the results of its investiga- tion of health insurance, sickness prevention and old age insurance, which ■was directed and authoriezd by said bill. Respectfully submitted, W. A. Julian, Chairman H. R. Mengert, Secretary. iii 23554 CONTENTS FAGB INTRODUCTORY STATEMENT History of the Commission. Chapter I SUMMARY OF FINDINGS AND RECOMMENDATIONS 1 Sickness and disability — Measures of prevention and care — Health insurance — Old age dependency and pensions — Recommendations — Summary of minority reports. PART I: SICKNESS AND SICKNESS PREVENTION Chapter II CHILD VITALITY 25 Infant Mortality — Physical examination of children — Health super- vision of schools — Institutional care for children. Chapter III NATIONAL VITALITY , 44 Mortality — Sickness and disability statistics — Estimates of the extent of sickness. Chapter IV SICKNESS, DEPENDENCY AND ECONOMIC DISTRESS 68 Chapter V DISABILITY RATES AND DISTRIBUTION ' 64 Report of Special Inquiry relative to the Disability of a Selected Group of Benefit Associations in the United States. H. W. KuHN, Ph. D. Chapter VI THE RESPONSIBILITY FOR SICKNESS 97 Industrial causes — Community causes — Individual causes. Chapter VII WHO PAYS FOR SICKNESS? 114 Chapter VIII LIABILITY FOR LOSSES FROM SICKNESS 122 Liability for sickness — Principle of the living wage — Benefits to each. V VI Chapter IX .PAGE MEASURES OF PREVENTION 130 (1) Medical and health service in Ohio — Medical practice — Nurs- ing service — Hospitals — Dispensaries — Health departments; (2) Feeble-mindedness ; (3) Tuberculosis. PART II: HEALTH INSURANCE Chapter X HEALTH INSURANCE 155 Chapter XI THE HISTORY OF HEALTH INSURANCE 176 --^(1) Obligatory insurance — Germany — Austria — Hungary — Luxem- burg — Norway — Servia — Great Britain — Russia — Roumania — Netherlands; (2) Subsidized voluntary insurance — France — Sweden — Denmark — Belgium — Switzerland. Chapter XII MATERNITY INSURANCE 185 (1) State assisted voluntary insurance — France — Sweden — Denmark — Belgium — ^Switzerland; (2) Obligatory insurance — Germany — Austria — Hungary — Luxemburg — Norway — Servia — Great Britain — Russia — Roumania — Netherlands — Italy; (3) Pensions — France — Australia. Chapter XIII MINORITY REPORTS ON HEALTH INSURANCE 192 Minority Report on Compulsory Health. Insurance. Robert E. Lee. Minority Report upon Subject of Health Insurance. Thomas J. Donnelly^ O. B. Chapman. PART III : OLD AGE AND OLD AGE PENSIONS Chapter XIV THE OLD AGE PROBLEM : Dr. John O'Grady 201 Chapter XV THE OLD MAN IN INDUSTRY : An Analysis of Census Data 204 Dr. John O'Grady. Chapter XVI OLD AGE IN HAMILTON AND CINCINNATI Dr. John O'Grady 214 Chapter XVII CARE OF THE AGED AND SICK IN OHIO INFIRMARIES 232 Dr. John O'Grady. Conditions for relief — Medical care — Tuberculosis and the infirmary — Infirmary population — Maintenance costs — ^ General care of inmates -^ Recommendations. yu Chapter XVIII PAGE THE AGED IN PRIVATE INSTITUTIONS De. John O'Grady 251 Chapter XIX PRESENT STATUS OF THE AGED 256 Age statistics — Foreign-born and aliens — Economic statistics — Sav- ings — Present methods of support — Pensions. Chapter XX OLD AGE ASSURANCE ; .'.-:. . 262 The hazards — Methods of applying the insurance principle — !^etom- mendations — Old age pensions in the United States. Chapter XXI — n^ THE COST OF OLD AGE PENSIONS 274 Chapter XXII "*)•* MINORITY REPORT ON OLD AGE PENSIONS M. B. HAMiioND 278 APPENDICES A. THE HEALTH INSURANCE MOVEMENT IN THE UNITED STATES John R. Commons, A. J. Altmeyer 287 Early writings on social insurance in the United States ■ — ■ Accident com- pensation — American Association for Labor Leg islat ion — • Investigat- ing commissions — Basis of agitation for compulsory Aealth insurance — Arguments against compulsory health insurance — Standard bill — Other proposals — Attitude of organized labor — ^ Attitude of employers — Attitude of medical profession — Attitude of druggists — Attitude of insurance companies — Attitude of other interests affected — Cali- fornia referendum. B. NATIONAL HEALTH INSURANCE IN GREAT BRITAIN 312 Edith Abbott. (1) The provisions of the act — ^the adoption of the contributory sys- tem in England — scope of the act — insurance fund — machinery for collecting contributions — benefits — arrears — ■ administration : insur- ance commissioners and committees — insurance carried by approved so- cieties — deposit contributors ; (2) The act in operation — medical benefit — approved societies and the insurance act — the administration of sickness benefit — sanatorium benefit and the tuberculosis problen; — maternity benefit in operation — conclusions. C. SICKNESS INSURANCE IN GERMANY. . .Henry J. Harris, Ph. D. 341 Persons included — Disability provided for — Benefits of the system — Administration Of the system — Finances of the system — Operations 1885-1912 — Conclusion. vm PAGE D. THE HEALTH OF OHIO COAL MINERS , 358 Emery R. Hayhurst, M. D., Ph. D. Introduction — Working conditions — Housing conditions — Sickness — Mortality — How miners cope with sickness and death hazards — Com- munity medical facilities — General summary — Suggestions for improv- ing health conditions in coal mining districts in Ohio. E. OLD AGE PENSIONS IN THE BRITISH EMPIRE. . . . W. B. Weidler 385 United Kingdom — New Zealand — Australia. F. SUMMARY OF HEALTH AND SANITARY LAWS OF OHIO 404 EsTHiER Helen Burns. G. SUMMARY OF TESTIMONY GIVEN BEFORE THE COM- ^ MISSION 410 INTRODUCTION The Commission on Health and Old Age Insurance was created by House Bill No. 461 (Laws of 1917, page 520) for the purpose of making an inquiry into the subject of sickness and the causes thereof; the loss to in- dividuals and to the public thereby; the adequacy of the present methods of treat- ment and care of such sickness and of meeting the losses caused by such sickness by existing insurance companies or associations, or otherwise; and the influence of working and living conditions upon the health of employed and unemployed persons and-methods for the prevention of such sickness and other related subjects. It shall also be the duty of such commission to make an inquiry into the subject of old age in its relation to industry and to the public interest and of the adequacy of existing methods of caring for aged workers. Pursuant to the act, Governor James M. Cox appointed the follow- ing as members of the Commission : W. A. Julian, Cincinnati. M. B. Hammond, Columbus. A. R. Warner, M. D., Cleveland. D. F. Garland, Dayton. O. B. Chapman, Dayton. T. J. Donnelly, Columbus. Dudley R. Kennedy, Youngstown. Mr. Kennedy on account of his absence in the work of the Inter- national Shipbuilding Corporation, resigned in April, 1918. Mr. R. E. Lee, of Akron, was appointed to fill the vacancy and attended his iiiitial meeting with the Commission June 18, 1918. At the first meeting of the Commission held September 5, 191 7, Mr. W. A. Julian was elected chairman of the Commission, and Mr. H. R. Mengert, of Columbus, was selected as secretary. At the meeting on December 8th, the appointment of John A. Lapp as Director of In- vestigations was ratified. Since that time a corps of assistants has been created for the conduct of the work. The Commission recognized early in its existence that the advice and assistance of certain groups of people should be specially invited, and asked that the Ohio Federation of Labor, the Ohio Manufacturers' Association, the State Medical Association and the Ohio Conference of Charities and Corrections appoint advisory committees to aid the Com- mission. The following gentlemen were appointed by the respective associations. ix SOCIAL AGENCIES W. S. Bixby, chairman-secretary, Charity Organization Society, Akron. C. W. Bookman, general secretary. Council of Social Agencies, Cincin- nati. John Melpolder, Portsmouth Welfare Association, Portsmouth. OHIO MANUFACTURERS' ASSOCIATION Malcolm Jennings, secretary, Ohio Manufacturers' Association, Colum- bus. Fred M. Black, secretary, Burke Golf Club Company, Newark.^ W. H. Stackhouse, manager, French and Hecht, Springfield. ^ STATE MEDICAL ASSOCIATION Qr. W. H. Snyder, former president, Ohio State Medical Association, / Toledo. Dr. O. P. Geier, chairman. Section on Public Health, American Medical Association, Cincinnati. Dr. G. E. Robbins, former president, Ohio Society for Prevention of Tuberculosis, Chillicothe. OHIO STATE FEDERATION OF LABOR W. M. Morgan, 6th vice-president, Ohio State Federation of Labor, Newark. G. W. Savage, district secretary. United Mine Workers, Columbus. Arnold Bill, secretary, Carpenters' Union of Ohio, West Cleveland. These committees and the individual members have given the Com- mission assistance which was of great value in formulating plans for the - investigation and in arranging for public hearings. The members of these committees have appeared from time to time before the Com- mission, both in private and public hearings, to give their views of the questions before the Commission. Immediately upon organization the Commission directed the col- lection of all available publications and data which had any bearing upon the problems before it. The material thus collected is being placed in a special file in the Ohio State Library for the use of investigators in these fields. Two conferences were held during the year by representatives of the state commissions which are studying health insurance for various states. The first was held December 27 and 28, 1917, in Philadelphia and was attended by members of the Commission and by the Director of 'Appointed April, 1918, to fill the vacancy created when the original ap- pointee Mr. R. E. Lee, of Akron, was made a member of the Commission. Investigarions. At this conference representatives from Massacliusetts, New Jersey, Pennsylvania, Wisconsin and Ohio were present. The second conference met in Cleveland on the invitation of this Commission on May 13 and 14, 1918, and was attended by representatives from California, Illinois, Wisconsin, Connecticut, New Jersey and Ohio. This conference was devoted to the consideration of methods and plans for investigation and of cooperation among the commissions in working out common problems. A summary of the proceedings of the first conference was published in the American Labor Legislation Re\iew for March, 1918. The pro- ceedings of tlie second conference were mimeographed and widely dis- tributed and a full summary was published in the American Labor Legislation Review for June, 1918. As a result of these conferences and special conferences of members of the executive staffs cooperative plans were undertaken and carried out and considerable interchange of studies was accomplished. ■ - The most importarit special investigations conducted are as follows : I. Examination of establishment arid mutual benefit societies to learn the extent of this form of insurance and the extent and severity of sickness. II. Collection and tabulation of statistics relating to the extent of fraternal sickness insurance and of trade union sick benefit funds. III. A study of the methods of care of the agfed in county infirm- aries and in private homes for the aged, including statistics on the causes of dependency. IV. A house to house study in the city of Hamilton to determine the extent of old age unemployment and dependency and the economic pondition .among people over 50 years of age. V. A study of child welfare and. of children's homes, both public and private, to determine the extent and character of health care.. -VI. A study of health hazards in mining and of. the provision for -health -protection in mining districts, . which - was made in cooperation with the State Department of Health. J' VIL A sickness survey covering several cities was, planned by the Commission but was abandoned on account of the influenza epidemic. The following investigators have been employed for special , assign- ments, lasting from a few weeks to six mpnths : J. A. Connors, special statistical and field wOrk and '■■i',- study of "fraternal sickness, insurance. - -- - .; ... .:...■;•.•: E)f.^ Johtr- O'Grady, studies of old age and old age "'--''•''■'; tlepeiiSency.' -; ■ ' '■'^''- -■■''-••■■ • • ■"■ -■'■i^i- Dr. E. R. Hayhurst, study of mining health hazards and medical service. Dorothy Ketcham, special research studies and re-, ports. Professor H. W. Kuhn, study of establishment and mutual benefit funds and other data. Mary Louise Mark, study of sickness statistics and special research. Christian Van Riper, research on material relating to feeble-mindedness and tuberculosis. W. B. Weidler, studies of fraternal and trade union sick benefits and other special studies. Eva B. Wheeler, studies of children's homes and child welfare. In cooperation with the Illinois Health Insurance Commission, special reports were prepared for the two cominissions on "The Health Insurance Movement in the United States," by John R. Commons and A. J. Altmeyer; on "National Health Insurance in Great Britain," by Edith Abbott and on "Sickness Insurance in Germany," by Henry J. Harris. Public hearings were held as follows: Springfield, November 30, 1918 2 meetings Cincinnati, December 2, 1918 3 meetings Columbus, December 4, 1918 8 meetings Toledo, December 5, 1918 2 meetiilgs Cleveland, December 6-7, 1918 4 meetings Dayton, December 16, 1918 2 meetings In addition to the public hearings eight executive hearings were held at which representative men and women appeared upon the special invitation of the Commission to give information upon particular aspects qf the investigation. Altogether about 1,000 persons attended these hearings and 105 gave testimony. Many others were consulted in person by members of the Commission and by its staff. Prior to the public hearings a preliniinary statement of facts and propositions was issued and distributed so that prospective wttqesses might confine their statements more directly to the problems which the Commission was considering. This niethod of conducting hearings proved very satisfactory and the Commission considers that the bearings were a decided success. The Commission acknowledges with ajjprecjatipn the evident spirit of cooperation and the services renderd by various state oflSces arid departments, by federal bureaus and by private organi?atiQns. Particu- larly, the Commission wishes to €3g5res§ its appreciation pi tjie assistance rendered by the State Department of Health, the State Superintendent of Public Instruction, the State Library, the Legislative Reference Bureau, the Industrial Commission, the Bureau of Vital Statistics, the Attorney General, the United States Commissioner of Labor Statistics, the Ameri- can Association for Labor Legislation, the National Industrial Con- ference Board and the National Social Unit. The particular thanks of the Commission are extended to the indi- viduals and organizations that assisted in the planning of and arrange- ments for the public hearings. CHAPTER I. SUMMARY OF FINDINGS AND RECOMMENDATIONS. SICKNESS AND DISABILITY— THE CAUSES AND EFFECTS. /. Child Welfare Statistics of child vitality disclose an unsatisfactory condition. The death rate of infants under one year of age is high, being from 9 I^er cgjjLsi to 10 per cent of all babies born. In Ohio of thosef^hat die Withift'one' ' year 48.3 per cent die within the first month. Tlie average for the regis- tration area of the country is 44.5 per cent; for the cities of the country 40.9 per cent and for the rural parts of the registration area of the coun- try 47.1 per cent. These figures measure the extent of prenatal and maternity care and show Ohio behind the country as a whole. The children who do not die appear to be growing up with far too many defects which may develop into the disabilities of later life. All the records in this state and outside show that from 40 per cent to 70^ per cent of all childreru in school are suffering from one or nlore defects; An intensive physical examination of 994 pre-school children in Cincin- nati showed that 53 per fce1i!®ftce,jiyerage height or above and 47 per cent below average. Two hundred thirty-one or 23 per cent had some serious defect. Statistics of the first draft showed that 32.2 per cent of the young men of Ohio failed to be admitted to the army. Fully 50 per cent of the causes for rejection could have been prevented in childhood. To meet the need for physical examination we find that half of the cities, including the larger cities, have some medical inspection but that only four of the counties are providing for any inspection at all, al-,, though statistics show that ^f ects are more prevalent among country children than among the children of the city. In only three or four citie§^ is the medical supervision measurably adequate. Public health nursing work has been developed to some extent for prenatal, maternity and infant care, ther?^%eing 480 public health nurses, but the beginnings are feeble when compared with-the magnitude of the need~i Cohere are , 40 counties in Ohio where there is no public health nursing work and in many of the others only one nurse is provided. '^Ty-iM^;--' II. National Vitality The death rate for the country has decreased from 19.8 per thou- sand in 1880 to 14.0 per thousand in 1916. The rate in Ohio in 1916 was (1) 144 3nd in 1917 14.8 per thousand. The death rate of Ohio compares favorably with the rest- of the country and with the civilized countries of the world. When we analyze the figures for the United States, however, we find that our death rate is excessive in the working ages, and that despite the general improvement, we have made no progress in reducing death rates in the population between 20 and 60 years of age. Certain diseases have increased their ravages in these groups, such as the de- generative diseases. It appears that rural health is not improving as satisfactorily as the health of the city. Certain diseases which ought not to be serious in the rural sections take a heavy toll in death and disability. ■^ U Available statistics of sickness show that every worker loses an ■Av&rage. of about nine days annually. Nearly three per cent of the peo- Djfe and of the workers are^ck at all times^w:- about 150,000 people.. /The million industrial worKer^k)se about 9,000,006 days from sickness. Twenty per cent of the workers have a disabling sickness each year. Sixty-five per cent of those who are sick for more than seven days will be sick for less than four weeks; 19 per cent from, four to eight weeks; 7 per cent from eight to twelve weeks ; 6 per cent from twelve to twenty- seven weeks ; 3 per cent for more than six months and 1.29 per cent over one year. ' ///. Sickness and Economic Distress The advent of sickness is the chief cause for raising the signal of economic distress. Among those who in times of economic distress seek aid from the private relief societies, 35 per cent to 50 per cent of the dependency is due to sickness. Among the inmates in Ohio infirmaries, sickness next to old age is the leading cause of dependency accounting for the presence as infirmary inmates of nearly 30 per cent. Among the aged cared for in private institutions sickness is again the foremost cause for dependency, being responsible for 40 per cent. Where poverty exists, it may cause sickness, sickness in turn aggravates existing poverty. A systematic method of meeting the expenses and losses incident to sick- ness would prevent many from falling into destitution and would pro- vide a stop-gap to the otherwise endless chain of sickness and poverty. Among those of somewhat larger means, among whom economic distress is manifested not by dependency but by borrowing, sickness leads all other causes. Thirty to 50 per cent of the chattel loans are attributable to sick- ness, and among the causes for loans made by the Morris Plan Banks, sickness figures conspicuously. The conclusion is plain that large numbers are living so close to the margin of income that unusual expenses such as those connected with illness force them to resort to charity or to borrowing to tide them over. IV. The Losses From Sickness The direct losses from sickness fall under three heads : I. Loss of wages. II. Cost of medical care. III. Loss of working power. The total loss of wages can be readily figured for any large group of workers and the individual loss for the worker who is sick Can like- wise be easily determined. It is a serious loss when it extends over a period beyond thirty days and in many cases beyond fifteen days. The cost of medical care for families averages from $20 to $40 in the industrial group. Five hundred and eight families earning from $1,000 to $1,300 in Cleveland, Lorain and Toledo, had an average ex- pense of $41.79. Six of these families had over $300 expense while three had none. The loss of earning power is not easily determined. From most diseases complete recovery is had but some diseases cut down the work- ing power. Fisher estimates that tuberculous persons lose 50 per cent of their capacity to work. Other studies disclose that the workers are often seriously handicaped temporarily or permanently by being crippled or otherwise, unable to do a f-ull man's work. V. The Factors Causing Sickness Three factors are clearly responsible for sickness the individual, the industry and society. < The individual causes sickness to himself by carelessness and reck- lessness ; by intemperance in eating and drinking ; by the use of intoxi- cants, drugs and tobacco ; by personal vice. The hazards of industry are dust, dirt, heat, fatigue, poisons, bad air, infections, bad light, dampness, inactivity and weather exposure^^^^ The community is responsible for the spread of communicable diseases. Filth diseases are due to community laxne'ss. Tuberculosis can be checked only by community action. Much of the failure to prevent health hazards of all kinds goes back to the failure of the community to properly educate children in health matters. A great deal of sickness is due to the failure of the community to enforce proper standards of housing, proper hours of labor, proper conditions for work and a^living wage. One or more of these causes of sickness are generally at work. While some diseases are almost entirely attributable to individual vice such as venereal diseases; or to the community, as typhoid; to industry, as lead poisoning; the great bulk of diseases is due to causes arising from a combination of individual, community and industrial causes. The worker lives in three distinct environments his home, his place of work and his local community. In his home, conditions affecting health are within his control, except so far as the character of the hous- ing which he can afford may not enable him to live decently. In in- dustry, such matters are outside the control of the individual worker, while in community health matters, the individual is affected by con- ditions for which the community as a whole is responsible. VI. Who Bears the Burden of Sickness The direct burdens of sickness are now borne almost entirely by the individual and the public. The individual loses his wages and gener- ally pays the cost of medical care. He also stands the loss in his de- preciated earning capacity. The public pays large sums for hospitals and for institutions for special kinds of sickness. The public also pays a large part of the cost of dependency which arises out of sickness. There is an investment of $80,000,000 in institutions and equipment for the care of sick and dependent people. The burden is distributed in Ohio by means of insurance to a slight extent. Fraternal orders paid to their members as sickness benefits in 1917 approximately $1,500,000; trade unions paid approximately $250,- 000; establishment funds distributed approximately $400,000; com- mercial accident and health insurance companies received $2,877,377 in premiums and paid $1,211,315 in losses; commercial health insurance companies received $417,149 in premiums and paid $177,950 in losses. Roughly speaking 35 per cent of the workers have sickness insurance for about 10 per cent to 15 per cent of their loss. Figures are not available to show the extent to which churches, lodges and clubs extended special relief in cases of distress. The amount received in premiums by the industrial insurance com- panies for burial insurance in Ohio, was $12,164,463 in 191 7 and the amount paid out in losses was $3,455,059. VII. Liability for Sickness Losses The recognition of the three causative factors of sickness, namely, the individual, the industry and the community, carries with it the recog- nition of the liability of each factor for losses incurred. If any one of these factors were the sole cause of sickness, then there would be no divided liability for losses. If the part which each factor causes could be segregated, then each couldbe charged with the losses it causes. The causes of sickness are so intertwined among the three factors as to make segregation of blame impossible and, therefore, it is necessary to apportion the whole liability among the three factors with reasonable fairness, leaving the way open for readjustments from time to time as conditions change. The benefits accruing to each from a comprehensive handling of the health and sickness problems should also properly be considered in establishing a basis for the payment of sickness losses. From a com- pulsory plan all three will naturally profit and therefore it would appear to.be reasonable to apportion the cost also on the basis of benefits. Lastly, the question should be viewed also from the standpoint of the minimum living wage. We recognize that every man who is willing to work is entitled to a living wage which includes present comforts, in decent living conditions, and proper provisions for sickness, unemploy- ment and old age. When wages are inadequate for present living neces- sities, sickness is caused. When wages do not make provision for sick- ness, dependency or destitution follows. By means of insurance only can the living wage provide with certainty for the contingencies of life. MEASURES OF PREVENTION AND CARE VIII. Health Administration and Medical Service The health of the people of Ohio is protected by a State Department of Health and by health boards and officers in the cities, villages and townships. The State Department of Health is well organized and noth- ing further is needed except the creation of new divisions and en- larged appropriations, from time to time, to meet the enlarging needs. The local health department consists of a board of health or health officer. There are 2 141 health vinits in the state. Only five cities have a full time health officer. The health officer of nearly all of the cities, vil- lages and townships give only nominal service and receive only a nom- inal compensation. The job is given often to the lowest bidder and generally no qualifications are required. The result is a health system quite incapable of promoting piiblic health or protecting the people in emergencies such as the recent epidemic of influenza. We find that the best thought and experience in the country ap- proves strongly the all time health officer. The rural districts, the villages and small cities suffered severely in the recent epidemic of influenza. They suffer frequent epidemics of smallpox, typhoid and other preventable diseases. Much of the failure to improve the health of the rural districts is traceable to the lack of public health work. Within the last few years the work of the public health nurse has been rapidly extended, and in September, 1918, there were 480 public health nurses in the state employed by public and private agencies. There are in Ohio approximately 8,000 physicians and 5,302 nurses, (not taking account of withdrawals for war service). The average for the state is one physician for 650 people. The distribution of physicians is uneven, there being one physician to 384 people in Columbus and one to 5,000 in some remote sections. Ten mining com- munities covered by investigation showed an average of one physician to 2,016 people. Tliere are 150 hospitals and sanatoria with about 25,000 beds for patients, besides the state institutions, county infirmaries, children's homes and private homes for the aged. Fifteen hundred beds are avail- able in municipal, county and district tuberculosis hospitals. Dispensaries number 30. The practice of medicine is principally on an • individualistic basis. There is very little of what has come to be known as group practice. There is some lodge practice, a little contract practice and a rapidly extending industrial medical service. From the best evidence available, it appears that the people of Ohio spend between $7,000,000 and $8,000,000 for patent or proprietary medicines annually. IX. Tuberculosis The ravages of this disease have been well-known for some time. New studies have only confirmed the fact that a tremendous toll is taken every year from the most productive period of life — that between 20 and 40 years of age. The exact extent of tuberculosis is not known. There were 7,453 deaths from this cause in 1917 but only 6,454 cases were reported by physicians to the State Department of Health. The best informed ex- perts on the subject agree that there are not less than 25,000 cases of tuberculosis in the state at all times and that probably the number is nearer 50,000. A widespread campaign has been directed against the disease for the last few years and substantial results have br;en achieved. The total death rate from this cause has materially decreased. The Ohio Society for the Prevention of Tuberculosis, local tuber- culosis societies and other groups have carried on a campaign of educa- tion, and have established dispensaries and clinics in many cities. Eleven county, district and municipal tuberculosis hospitals have been established with 1,500 beds. A state sanatorium has also been established with 175 beds. These facilities, it is apparent, are not able to take care of more than a small fraction of the cases. The result is that the tuber- culosis hospitals have become asylums for the worst cases and the cura- tive and preventive work is subordinate. Authorities agree that the efforts should be directed to getting the patients under care before it is too late to arrest the case. All agree that the difficulties are great because men with dependents cannot leave their work to go to a sanatorium without some provision other than charity for the maintenance of dependents. Men therefore remar: at work until it is too late. ' X. Feeble-f making any provision whatever for his declining years in accordance vith the generally recognized principle of self-help? Would not a sys- em of old age insurance, to which the worker himself made direct inancial contributions as in our recommended scheme of health insurance, )e a better method of meeting the problems of old age and invalidity ? VI. Can the revenue system of the state be speedily revised in iuch a way as to provide at this time the large appropriations required to lupport a system of old age pensions? If not, had the plan of affording elief ■ for old age not better be postponed until an improved and suffi- :iently flexible revenue system has been adopted and in the meantime further study be given to this problem of old age poverty and its pos- ;ible solutions? It is because I do not find a satisfactory answer to these questions n the testimony of the witnesses who appeared before the Commission lor in the evidence submitted to the Commission by its investigators at east in time for our consideration that I cannot bring myself to the joint of recommending the plan for immediate adoption by the Legis- ature. Further study of the experience of other countries with old age jensions might lead me later to favor such a plan for Ohio. PART I: SICKNESS AND SICKNESS PREVENTION (23) CHAPTER II INFANT AND CHILD WELFARE The American people have awakened thoroughly, though tardily, to the supreme importance of protecting the children of the land as the first step in the conservation of national vitality. The extreme individ- ualism which characterized our civilization for so long has practically passed away so far as children are concerned. We no longer leave the care of the child to caprice, ignorance or selfishness under the doctrine of individual liberty but we interfere at any point where the welfare of the child is endangered. Compulsory education is all but universal in this country ; child labor laws of varying effectiveness are on the statute books of almost every state; juvenile courts protect the children against neglect and maltreat- ment; crimes against children are severely punished and the health and morals of children are given special attention. The clear purpose of society is that the foundation of the future, which rests on the children of the present, shall be buttressed with the fullest care which can be bestowed, for upon such care may turn the fate of the nation. The next step in this project is the promotion of the physical wel- fare of children. Beginnings have already been made and in some places much has already been accomplished. The field of operations has at least been charted and valuable experience gained. Universal approval by all thinking people has been secured for the proposition that the state must see to it that every child shall have the fullest chance for development free from the handicaps, physical and mental, of heredity and environ- ment, so far as it is possible. INFANT MORTALITY A brief recital of facts will disclose the significance of the present and past neglect of child care. In 1915 there were 13,127 deaths of chil- dfen under five years of age in Ohio or 19.8 per cent of all deaths re- ported, although children under five constituted approximately 10 per cent of the population. The mortality rate in 1915 for children under five was 27.9 per thousand of the population under five. (25) 26 The rates for the seven leading cities in 191 5 were: Number of Births, Number of Deaths under One Year of Age and Infant Mortality Rate per 1,000 Births for Certain Cities tn Ohio, 1913. City. Number of births Number of deaths under one year of age Rate per 1,000 births 16,429 7,372 3,923 4,627 2,520 2,991 2,615 1,829 619 311 479 388 265 233 111.3 83.9 79.2 Toledo 103.5 153.9 88.5 89.0 Total 40,477 4,124 101.8 The total number of live births in Ohio in 1915 was 105,901. The mortality rate was 91 per thousand births or 9 per cent of all births.^ In New Zealand during the ten months ending Dec. 31, 1913, 467 stillbirths were registered; 679 in 1914; and 728 in 1916; a toital of 1,874 and an average of 661.3 per twelve months. In Victoria during 1912, there were 962 stillbirths; 971 during 1911 ; and 1,105 during 1916 ; a total of 3,308 for the three years and an average of 1,012.3 per year. The fairest index of maternity and infant care is found in the sta- tistics of baby deaths during the first few days after birth. During the six year period from 191 1 to 1916 there were in Ohio 61,854 deaths of children under one year and of these, 9,246 died within one day, 20,406 died within one week and 29,884 within one month. nt of Deaths ^exclusive of Stillbirths) Occuring within Certain Periods of the First y^ear of Life for the Registration Area and Specified Subdivisions , 1911 to 1916 Per Cent Area. Per cent of all deaths in the first year of life occurring within One day One week One month The United States Registration Area Cities in the Registration Area.. Rural Registration Area Ohio Cleveland Cincinnati Columbus Toledo Dayton 14.2 13.1 15.fi 14.9 13.2 18.0 17.0 18.3 19.0 29.8 27.9 31.9 32.9 27.9 30.0 34.6 33.7 37.3 44.5 40.9 47.1 48.3 42.0 48.7 47.6 47.0 50.2 'Infant mortality rates for new Zealand and Australia, which have the lowest infant mortality fates in the world, show the great reduction in infant deaths possible. During the ten year period 1906 to 1915 the mean average death rate for infants under one year was 53.63 for New Zealand; 71,22 for New South Wales; 71.22 for Victoria and for Australia 70.29. 27 These figtires place Ohio and four of the Ohio cities in a bad light. The percentage of infant deaths within the first month is higher than in the country as a whole, higher than the rural sections of the country and far higher than the rate in the cities of the country. DEFECTS OF CHILDREN , These figures relate to deaths of infants. If we could have similar figures which would disclose the extent to which the children who do not die are handicapped by physical weakness as a result of inadequate or ignorant care or by criminal neglect, there is no doubt that people would be startled. Such figures are now being made available for the first time in several cities for the period of early infancy and common observation alsQ supplies part of the deficiency of figures. The number of under- nourished, weak, anemic and defective children is not fully known sta- tistically but every social worker and close observer knows that it is large. We know, from observation as well as statistics, that a great deal of physical weakness and permanent disability is caused from seeds sown during the early years. The most complete concrete evidence of the extent of physical defects comes to us in the medical examination of school children. Many data have been gathered on this point all tending to show that at present from 50 per cent to 70 per cent of all children of school age are defective to some extent. The figures for the city of Cleveland are instructive on this- point. Medical inspecion has been in vogue for several years and corrective measures have been greatly ex- tended. Physical Defects among School Children, Cleveland, J912 to 1918. Year. Number examined Number Per cent 1912-1913 . . .■ 61,578 64,187 74,725 81,398 28,323 26,329 82,422 39,017 46 7 1913-1914 41.0 1914-1915 . . : 43i 4 1915-1916 47.9 19W-1917 1917-1918 79,857 28,300 35.4 Pennsylvania has the most complete plan for medical inspection in the rural districts and small villages of any state in the union. Medical inspection is compulsory unless the district votes against it and in 1915-16, 2,156 of the 2,377 districts had such inspection under the direc- tion of the State Department of Health. In the year 1914-15 there were 469,199 school children examined, of whom: 335,427 or 71.4 per cent were found to have physical defects ; 184,900 or 39.3 per cent had one defect and 150,527 or 32.1 per cent had more than one defect. The total number of defects was 551,671. 28 Defects and Diseases Found among Rural School Children of Pennsylvania, 1914-1915. Defect or disease Number of pupils Adenoids Breathing Cervical glands Deformities Eyesight Goitre Hearing Malnutrition Nervous diseases .... Quarantinable diseases Skin diseases Teeth Tonsils enlarged Tuberculosis 6 22 22 1 6 253 123 ,713 ,837 ,874 ,645 ,260 879 ,368 ,578 756 56 196 ',551 ,222 789 It will be observed that the great majority of these defects are cor- rectible and that many if uncorrected are likely to lead to more serious disorders. Defective teeth, tonsils and adenoids are directly responsible for much physical suffering and permanent disability. That early atten- tion to the beginnings of these defects and a comprehensive plan for treatment and correction will ward off later serious evils is the unanimous opinion of medical and lay experts. The following figures from Cincinnati summarize the statistics of the physical examination of 994 pre-school children. Forty-seven and three-tenths per cent were found to be below the average in height ; 14.6 per cent above the average; and 23.2 per cent of those examined were found to have serious defects. Report of Exarmnation of 994 Children between the Ages of 2 to 6 Years, made at the Social Unit in the First Six Months of 1918. Age groups All ages Under 3 months 3 months to 6 months. 6 months to 1 year 1 year to 3 years 3 years to 6 years Height for age is Average 377 52 25 41 93 166 pq 141 24 10 20 36 51 O 236 28 15 21 57 115 Above 146 10 10 4 43 79 100 7 10 4 38 47 O Below 471 7 24 51 147 242 255 3 9 33 79 131 O 216 4 15 18 68 Ill- Serious defects 231 5 7 13 49 157 ^ U m 115 116 1 4 4 3 11 2 24 25 75 82 29 THE DRAFT STATISTICS The next evidence of the physical condition of young people to be considered is that produced by the first draft of men between twenty- one and thirty-one years of age. In this draft up to November 20, 191 7 all men were examined by local boards and accepted or rejected on their physical fitness. We thus have an accurate picture of the physical con- dition of men in early life. The figures down to November 20, 1917 include the total number of men examined by local boards, or 2,510,706 and the total number of men rejectedby local boards, or 730,356. Thus, 29.11 per cent of the total number of men examined were rejected for physical disability by the local boards. Of the total number called to camp, up to November 20th, 5.8 per cent were rejected by the camp surgeons. It appears then that of the 1,779,950 men passed by the local boards, 103,237 would have been re- jected by the camp surgeons, making a total rejection of 833,993 '^^ 33-2 per cent rejected. In the State of Ohio 167,828 men were examined by the local 'boards; of this number 43,771 were found physically unfit, or 26.08 per cent. At Camp Sherman, which included troops from Ohio and Pennsylvania, 8.33 per cent who had been passed by the local boards, it is estimated, would have been rejected by the camp surgeons, thus in- dicating a total rejection from Ohio of 54,104 or 32.2 per cent. The Provost Marshal's Department picked 10,000 names, representing eight camps, and from these data tabulated the causes of rejection which are given below. Causes of Physical Rejection.^ Causes of physical rejection Number rejected Percent of total num- ber rejected 9. 10. 11. 12. 13. 14. 15. 16. 17. Total number of cases of physical rejections con- sidered Alcoholism and drug habit Physical undevelopment Teeth Blood vessels Bones Digestive system Ear Eye Joints Muscles Respiratory Skin Flat Foot Genito-urinary (non-venereal) Genito-urinary (venereal) . . . Heart disease 10,258 79 416 871 191 304 82 609 2,224 346 66 161 118 375 142 438 602 0.77 4.06 8.50 1.86 2.96 0.80 5.94 21.68 3.37 0.64 1.56 1.15 3.65 1.39 4.27 5.87 1 United States, Provost Marshal General, Report to the Secretary of War, 1918, p. 47. 30 Causes of Physical Rejection — Concluded Cause of physical rejection Per cent of total num- ber rejected 18. 19. 20. 21. 22 23. 24. Hernia Mentally deficient Nervous disorder (general and local) Tuberculosis Underweight Ill defined or not specified Not stated 7.47 4.53 3.77 .5.37 1.59 .91 7.89 It will be observed that the great bulk (authorities say 6o per cent) of rejections were due to causes which probably would have been pre- ventable or correctible if taken care of in time. A comparison was made also between selected groups of men in cities of over thirty thousand population, and in the country districts, with the following results ^ : Per cent accepted Urban and rural rejections Number and rejected Urban areas, total persons physically examined 35,017 Accepted 25, (MS 71.53 Rejected 9,969 28.47 Rural areas, total persons physically examined 44,462 Accepted 32,030 72.04 Rejected 12,432 27.96 Early neglect has been shown to have a direct and cumulative effect on physical unfitness by the statistics of infant mortality, of medical in- spection of schools and of the first draft. Only the more obvious and permanent defects have been disclosed by the examinations. We do not know statistically the extent to which neglect in childhood undermines the constitution of men or predisposes to disease. The effect of malnu- trition in producing scurvy and rickets, which in time may result in per- manent disorder, emphasizes the vital importance of the most painstaking attention to every condition in childhood which may be laying the foun- dation for disability. MEASURES OF PREVENTION There is sufficient evidence to prove the case for social action to pre- vent the defects of childhood and youth "from becoming the chronic disa- bility of the working life, as well as to make the education of youth and their preparation for life efficient. The excessive infant mortality, and especially the stillbirths and deaths within the first month of "life, show the necessity for prenatal care and the education of mothers. The economic waste, to say nothing of the physical suffering of mothers and 'United States, Provost Marshal General, Report to the Secretary of War 1918, p. 47. 31 babies, demands action. The convincing evidence of infant mortality within the first month after birth should not need elaboration to prove that a -social program for the care of maternity is demanded. That 8,000 children die annually in Ohio either before or soon after birth is a suffi- cient call for action. Unquestionably a lower infant mortality rate is better than an increased birth rate in sustaining society. The brilliant campaign of the United States Children's Bureau, ably conducted by the women of the state under federal guidance, already has brought the question of infant and child care to thousands of intelligent parents in the state. Action is needed now to garner the fruits of this campaign. Interest has been aroused not for the sake of interest but for the sake of the babies. Bad conditions discovered must now be corrected. Definite caje must now be supplied. Children's year should be made the beginning of a widespread plan for the physical care of infants and children. Steps which should be taken are: I. The increase in the number of visiting public health nurses in cities and counties and an enlargement of the facilities for aid to all people regardless of their economic status. II. An enlarged bureau in the State Department of Health for the supervision of public health nursing in its relation to pregnancy and for the dissemination of practical information to mothers. III. Broader education for child care in the vocational work of the public schools and the establishment of part time courses for mothers. IV. Provision for adequate medical, hospital and nursing facilities within reach of all people. V. Prohibition of employment of mothers before and after child- birth. Public Health Nursing There are_ 480 public health nurses in Ohio. Three hundred and sixty of these are employed by the public and 120 by private agencies. Their work is universally approved and is so vital to social welfare that the Council of National Defense in a resolution early in the war declared as follows : Realizing that public healtli nurses are essential to the carrying on of child welfare work, we recommend that every possible effort be made to prevent these especially trained nurses from being withdrawn from such work and that public health nursing be officially recognized as war service. No institution has been so completely approved by everyone as public health nursing; a rapid increase in the number employed and the in- tensification of their work is concrete evidence of their efifectiveness. The nurses have approached the problems of prenatal and maternity care with the greatest fact. They have succeeded in breaking down in- dividual as well as social barriers and are welcomed as friends and ad- 32 visors into many thousands of homes. The nurse occupies a position of peculiar importance, she combines knowledge and skill, comes at a time when she may be of the greatest assistance and comfort not only to the mother but to the family as well. She gives advice concerning prenatal or personal care and actually assists in the performance of such care. This affords the opportunity of making additional suggestions concerning the care of the other children, diet, sanitation and household manage- ment. Later visits are made to follow the development of the child, to assist in the prevention and correction of defects and to secure proper care and attention for the child until he is old enough to come under the supervision of the schools. The public health nurses are now under the guidance and supervision of the State Department of Health to a limited extent, but adequate support has not been provided. A bureau should be fully equipped and adequately financed for the direction and extension of this work. Educatiom for Child Care The passage of the Smith-Hughes act by Congress in 1917 stim- ulated the movement for vocational education by giving national aid to approved kinds of vocational education conducted by the states. A pro- gressive movement has already begun in Ohio and, undoubtedly, com- plete plans will give full recognition to this form of education. Under this plan, domestic science or home economics is recognized as one of the approved forms of vocational education, and aid is given to any state to supplement state or local funds in promoting such education. Infant and child care should be selected for special promotion in the home economics work in the schools of the state under the stimulus of the federal law. A similar situation obtains through the Smith-Lever act which gives federal aid for extension work on farms and in farm homes. The exten- sion worker in the farm homes should become also a counselor to farm- er's wives in the care of infants and children. They might well take on some of the health duties of the public health nurse if indeed they should not be rural public health nurses. Work of this kind is already begun by the extension division of the Ohio State University and should be greatly extended both to rural and city homes. The figures heretofore quoted showing the greater percentage of infant deaths in the first 30 days in the rural districts is eloquent evidence of the need. Maternity Facilities Facilities for maternity care should be provided with the object of insuring proper medical care and obstetrical service. From 700 to 800 mothers lose their lives in childbirth in Ohio each year. Every other year, therefore, a Titanic goes down with 1,600 mothers, most of whom 33 could have been saved by proper obstetrical care and' nursing. The loss of infants has already been discussed. Clearly there is a public responsibility in this matter. The way we meet such problems is the barometer of our social life. We could not sit still and count the annual toll without being stirred to action even if it did not concern the up-building of the race. When, to the claims of humanity, is added the fact that the nation's life depends ultimately upon the care of mothers, infants and children, there is no one who will dis- approve active social interference. Matet^tity Protection Lastly comes the matter of the legal protection of working women at maternity. Almost every European country prohibits the employment of pregnant women for one or two weeks before confinement and for three or four weeks after confinement. Four states in the United States have similar laws. Massachusetts and Vermont prohibit work for two weeks before and four weeks after confinement. Connecticut makes the limit four weeks before and four weeks after confinement, and New York forbids employment for four weeks after confinement. There is such a manifest necessity for a law of this kind that Ohio should not delay its enactment. With the increasing number of married women in industry, due to the war, the necessity is greatly enhanced. HEALTH SUPERVISION OF SCHOOLS When children have become old enough to enter the schools, the problem of health supervision is emphasized and the means simplified. The assembling of the children makes possible a system of medical in- spection and health supervision and for the first time shows the extent of physical ills and defects. The isolated child or the child in the home is hard to single out and treat, but the group lends itself readily to in- spection and supervision at a low cost. We have already pointed out the extent of physical weakness dis closed by authoritative data. This material shows that there is a large percentage of defectiveness in children and youths in the prime of life. From the material at hand, we quote with approval a leading work on .school health : Serious defects of eyes, ears, nose, throat, lungs, teeth, glands, nutrition, heart action, nervous co-ordination and mentality have been discovered with sur- prising frequency wherever they have been looked for. Statistics on these mat- ters have been so indefinitely extended and (when we make allowance for cer- tain differences in procedure) have given such uniform results, that we can safely say that in any school system, no matter where it may be located or to what social classes its patrons belong, from 60 to 75 per cent of its pupils are suffering from one or more physical defects serious enough to require skilled attention.' 'Hoag and Terman, Health Work in Schools, 1914, p. 2. 34 For several evident reasons responsibility for the physical health of the child rests upon the school as the agent of society. I. The child may be adversely afifected by the school work or may suiifer from causes for which the school is responsible. II. Defects, physical or "otherwise, may prevent the child from re- ceiving full advantage from the schools. III. Uncorrected defects in childhood lead to more serious defects and disorders of later life. IV. The aggregation of children facilitates the spread of contagious diseases unless the strictest supervision of health and personal hygiene is maintained. V. Children should be taught to develop habits of permanent ad- vantage to themselves not only by a knowledge of the exactions of health but by careful training in the application and use of recreation and play. VI. The youth entering industry should be guarded carefully. Conditions Adversely Affecting Children When the child enters school, he is compelled to adapt himself to new and strange surroundings and to live an unaccustomed life for sever- al hours each day. There is an obligation here to see that he does not suiifer ill effects from the change. The transition to books, indoor life, school discipline and application may subject some children to injury to say nothing of the worse evils to which some are subjected, namely, in- sanitary surroundings, cramping seats, poor ventilation, bad lighting, dust, etc. All children cannot be subjected to the same discipline with- out injury tO' some. Throughout the entire educational course from primary school to university, care must be taken not to wreck the physical, mental or nervous powers of those children who cannot stand the strain of the regular course of study, or the discipline and limitations of the school. The supervision of the child's health must, therefore, include a study of the school environment to search out insanitary conditions or dangerous practices inimical to his best development. The child himself must be studied so that harmful practices may be avoided. The attempt to subject all children to routine practices may bring about serious results among those who suffer from bodily or mental deficiencies. Defective eyesight, uncorrected, prevents the constant appli- cation to books possible for a child with normal sight. It may be the last straw which breaks the back of an undernourished child to require the same application to work as we require of others. To try to educate a child incapable of assimilating knowledge is very evidently a waste of time and money for the state and a dissipation of the limited strength and ability of the child. School efficiency demands the reformation of all conditions which prevent the best results from the school work. Children must attend school, if they are to receive benefit from the edu- 35 cational opportunities offered. Parents who seek to evade the provisions for compulsory attendance should be severely punished. Children re- tarded in their development by either physical or rnental defect should not be excluded from school. So far as possible the defects should be corrected and the child returned to his place in school. If the defect cannot be corrected, the school should provide the kind of education which will afford the child the opportunity for his greatest possible de- velopment. Compulsory education as a social measure can be justified on no other basis. With 50 to 70 per cent of the children in the schools suffering from some physical handicaps, mostly correctible, the neces- sity and opportunity for improvement is apparent. Physical Defects The extent of bodily defects made evident by the rejections of the first draft and corroborated by every other investigation on the subject emphasizes the need for action in early life to correct and prevent defects. It is apparent that a great many of the disabilities arising later in Hfe de- velop primarily as the result of neglect in childhood. Many thousands might have better eyesight if corrective treatment had been given. Of those rejected in the first draft, 21.6 per cent were rejected for this one cause. What proportion of this was brought about by neglect of the infant, by bad lighting in schools or uncorrected defects in childhood, we do not know, but competent specialists assert that practically all might have been prevented. Secondly, a long train of dreaded diseases which appear in later life arise as the result of the malnutrition of babies and children. Un- fortunately, we do not have detailed information concerning the physical condition of the school children of Ohio, such as that for New York City,'- but the statistics which we have, give ample evidence of the ex- tent to which the children are underfed and poorly nourished. Only a very small percentage of children receive proper and adequate food. This inattention to the diet is not by any means confined to the poor. The children of the wealthy and well-to-do are neglected quite as badly, although in this case it arises rather from ignorance of what a child needs than from, a lack of nutritious foods as among the poor. Chronic ills may be established in these early years from which the innocent victims * A survey was made for the purpose of determining the extent of under- nourishment among children of school age in New York City. Of 171,691 children examined, 29,781 or 17.3 per cent were found to be in normal condition so. far as nutrition was concerned ; 104,908 or 61.1 per cent were in passable condition -not entirely well nourished, but not showing signs of undernourishment; 31,718 or 18.5 per cent were definitely undernourished and in need of immediate attention ; 5,284 or 3.1 per cent were in an advanced stage of inanition and should be placed immediately under medical care. (New York City Department of Health, Bureau of Child Hygiene, Nutrition Survey, December, 1917, Public School Chil- dren, Burough of Manhattan.) 36 never escape. Among the very poor and destitute the ill effects are nothing less than appalling. Strange indeed that we have not taken hold of the problem in a thorough fashion before this, when such plain evi- dence concerning the eif ect of neglect upon children is seen on every hand in the physical and mental condition of thousands. The children's hospitals which serve the poor furnish distressing testimony of the starvation of babies and children. It may be an over- statement even for the city of London, but the following quotation from Webb's "The Prevention of Destitution" at least shows the' possible con- sequences : "By far the most serious matter affecting the commonwealth in every pos- sible way- at the present time,'' writes a great authority on children's diseases, referring to infantile mortality, "is the condition of babies who do not die, but who are reared, in a condition of hopeless malnutrition. Let us consider, for in- stance, one disease — rickets. Its effect on the nervous system is of the most far-reaching character. Of the 'convulsions' which cause the death of babies at about twelve months of age, rickets is practically the sole cause. At a later state of life the manifestations of the injuries caused by this disease are seen in epilepsy and in insanity. The lunatic asylums are largely occupied at the present time by cases of insanity arising from injuries of the nervous system by rickets. Adenoid growths, one of the common troubles of childhood, are practically caused entirely by deformed structure due to rickets. If you go to the chest hospitals and select the patients who are under treatment for pulmonary tuberculosis, you will find the majority of them are suffering from deformities of the chest due to rickets. The pulmonary disease is simply a secondary result of the injuries to the chest and of the injuries to the tissues arising from rickets. All sorts of deformities which go to make up the number of cripples that we are acquainted with, are caused by the same disease and in addition to specific disease and deformities, rickets is responsible for a general and permanent enfeebleraent of mind and body." And rickets is a disease which, though widespread enough, is practically confined to the children of the slums and is caused definitely by neglect, funda- mentally by malnutrition. It is the outcome not of bad stock but of bad environ- ment; and if we dim at the production of a fine adult race we cannot afford to leave that bad environment alone. That which kills off some, damages many more; and even if we did not much want to lower the infantile death rate, we should still need to do our utmost to diminish the damage raite among the sur- vivors, which (as Dr. Newsholme has once more conclusively demonstrated) varies in very close relation to the death rate.^ Tuberculosis is generally considered a fatigue disease and as such finds a particularly fruitful field for development in the devitalized child. The ultimate effect of a congenital venereal infection may be equally serious. Measles, scarlet fever, whooping cough and other so-called "children's diseases" to which parents ignorantly expose their children with the mistaken idea that "they might as well have it and have it over," leave a long train of trouble especially when accentuated by a lack of care, — troubles which may culminate finally in permanent disability. 'Sidney and Beatrice Webb, The Prevention of Destitution, 1912, pp. 50 51. i7 Contagious Diseases The necessity for preventing the spread of contagious diseases among children and by them among the homes, is so apparent that no argument for the provision of ample facilities should be necessary. The entire sys- tem of medical inspection was established to check the spread of con- tagious diseases. The trouble with the plan has always been that it went no further than exclusion from school. No thought was given to the care of the sufferer and, consequently, it never has become a constructive service. The school as a potential distributor of contagion has a special duty to perform in order to obviate the. possibility of evil consequences to children. Health Education For the use of the Commission, the Superintendent of Public In- struction obtained data relating to the teaching of physiology and hygiene in the public schools. The replies indicated that practically every school had some kind of instruction along this line of work. In many, some instruction was reported in the lower grades as well as in the seventh and eighth grades. Text books were in use in practically all of the schools. The interest in these subjects is commendable but the methods of teaching do not measure up to the ideals of health education. In the first place the subject is generally taught for the sake of the subject in- stead of the child. The creation of health habits is subordinated to formal instruction. It is taught as a science rather than as an art to be practiced daily. The study of anatomy and structure is emphasized at the expense of a practical knowledge of healthful living. So far as the average child is concerned, it is most important that he receive a thorough training in the formation and acquisition of permanent health habits; consideration of the study as a science is secondary. In the second place too much time is spent in the study of the harm- ful effects of alcohol and narcotics. These evils should be emphasized but not to the exclusion of -other bad practices equally destructive. Lastly, the study is now a negative one. The emphasis is placed almost entirely upon fear of disease. Undoubtedly, if the process were re- versed and the children were taught the joy of exuberant health, the negative side would tend to diminish. Knowledge regarding community health should be flung so broadcast that . all society may recognize unhygienic conditions, and feel the obligation and urgency of doing something to remedy them. Personal hygiene made so to function in the lives of children would be an enormous asset to them and to society.^ 'Alice Boughton, "Household Arts and School Lunches," Cleveland Educa- tion Survey, 1916, p. 69. o o 38 We should teach what to do to promote health, making the preven- tion of disease an entirely second consideration, because children who are taught to do those things which bring redundant health will not need to know so much about the things which prevent disease. The inculcation of health habits will in itself prevent disease. If children were taught an intimate knowledge and respect for their bodies and that disease comes principally from the violation of certain easily observable laws of health, their development would be more satisfactory and replete. It is better for the child to think rather in terms of freedom from disease than in terms of quarantining himself against infection. A child who is taught to take care of his teeth habitually, need not be taught the effects of pyorrhea; correct habits of reading reduce the necessity for detailed in- struction in the evils of eyestrain ; good ventilation makes unnecessary the teaching of the results of bad ventilation ; rational education in food selection tends to remove many of the dangers of degenerative diseases; a wholesome respect for one's mental and physical powers will go far toward preventing the evils of alcohol, narcotics, drugs and other poisons. Physical training and supervised play can be made to contribute ma- terially to physical well-being. Health Supervision for Wage-earning Minors It is important that when children leave the schools and enter in- dustry, the protecting care of society shall follow them, otherwise the health work of the schools may be undone. Vocational guidance must become guidance for physical as well as for vocational welfare. The child labor laws of the State of Ohio prevent the industrial exploitation of boys under fifteen and girls under sixteen years of age% but as soon as the age limit is passed, children may enter any industry regardless of its effect upon their physique. Careful supervision should be instituted, in order that no person under eighteen years of age enters industry without a physical examina- tion. A careful survey of the particular process to be performed .'-.hould also be made in order to prevent harmful results so far as possible. Per- sons under eighteen should be excluded from occupations and processes which are detrimental to their physical welfare and development. Ohio legislation already makes a beginning in the matter of physical exami- nation before entering industry, but its terms are permissive and its meaning not entirely clear. CHILDREN'S HOMES In addition to the children in the public schools, there are approxi- mately 15,500 children who during some part of the year are wards of the state. The normal dependent children are cared for in county or 'Ohio General Code, Supplement, Sec. 6330-6. 39 private homes and the abnormal and delinquent in state institutions, such as state schools for training the blind and deaf. An institution is not the proper place for a child to develop normally. Opportunities which come as a matter of course to the child in the home, are denied the child in the institution unless specifically planned. If circumstances, usually those over which the child has had no control, have forced him into an institution, the state acting as foster parent has the opportunity of pro- viding the best possible environment and of establishing a general stand- ard for child care. That this point of view is not congenial to some of the managers, is shown by one matron who remarked, "I do not believe in giving these children anything which the poorest taxpayer's children do not have." An inspection of about 60 homes showed that the medical care provided was freqviently insufficient and incompetent: 4 homes had resident physicians; 7 had physicians who called at intervals; 18 called the physician when his services were deemed necessary and 15 had a resident trained nurse. Forty homes made no arrangement for regular visits by a physician. The thorough medical inspection of entrants is of particular importance in the case of children, not only to discover and correct defects but to prevent the spread of contagious disease. Most homes provided a physical examination more or less superficial in char- acter. No institution provided a thorough examination on entrance and periodical examinations thereafter. Physical defects even when noted were not always corrected. Adequate dental care was not provided. When an institution is situated in a city which provides for thorough medical inspection through the public schools and a public health nurs- ing service for follow-up work, an arrangement for adequate medical care through the city dispensaries or hospitals may be made. Personal training in the establishment of cleanly and health giving habits was not provided. Individual tooth brushes were provided, but common soap, wash cloths and towels were found in 45 institutions; common combs and hairbrushes in 40. Bathing facilities were usually inadequate. In one institution the two bathrooms could not be heated, so were not used during cold weather., Supervised play and indoor recreation are important factors in the development of the child. Adequate provision is usually lacking. However, swings, ladders and balls are usually found. One institution provided a large wading and swimming pool for the children and each child was required to take a shower bath before entering the pool. The physical surroundings of the buildings were found to be very satisfactory in some cases but in several there was no provision for a playground, an essential to any institution housing children. The build- ings themselves were often in barren and undesirable locations, much in need of repairs with floors rough and unpainted, were without screens and poorly ventilated. The dormitories were hght and airy but fre- 40 quently were equipped with old beds and thin straw matresses. In some institutions the children were required to take their naps upon the floor in order to avoid mussing the beds. An institution represents the line of least resistance. At best in- dividual differences and the development of personality must be neglected. On the other hand, through the leadership of competent and trained persons excellent facilities for care can be and have been estab- lished. THE CORRECTION OF DEFECTS The Commission has given consideration to the problem of remedy- ing the conditions which medical inspection discloses. It would be idle merely to discover defects and leave them uncorrected. A follow-up system is unquestionably desirable to improve all conditions which are remediable. Failure to provide adequately for this part of health super- vision has been the principal weakness in this' country. Statistics as to the extent to which corrective measures are applied are not entirely reliable as to the actual correction of important defects. Some cities report correction of as high as 75 per cent of the defects re- ported to parents. In others, the percentage is much lower. For ex- ample, in Cleveland, where the work is known to be very efficient, only 30 per cent to 40 per cent of the defects are reported corrected. The dif- ference apparently arises from the fact that trivial cases are not reported in Cleveland and therefore do not swell the percentage corrected. The important consideration is to correct those conditions which are the fore- runners of physical disability. The health supervision of children should include regular physical examinations by physicians and follow-up work by nurses. The parents should be notified of remediable conditions and every effort should be made by the nurses to induce parents to secure such treatment. Where the expense is too heavy to be borne by the individual, public provision for securing attention should be provided. The adoption of this program will help Ohio to realize the ideal of health supervision expressed by Dr. George D. Strayer, president of the National Educational Association. We will no longer be satisfied with medical inspection which discovers and records defects. We must rather seek the highest possible type of physical- efficiency through the removal of remediable defects, by providing the conditions necessary for normal physical development and by inculcating an ideal of physical cleanliness, vigor and efficiency. THE HISTORY OF HEALTH SUPERVISION OF SCHOOLS Medical inspection of schools is a distinctly modern development. In fact it is largely a twentieth century institution. In less than twenty- five years almost every civilized country has adopted it in some form. Those countries which have accomplished the most are England, France 41 Japan and Germany. Medical inspection is quite universal in these coun- tries and each has developed some strong features. In England the impetus for health supervision was given by the disclosures of unfitness in the physical examination of volunteers for the Boer War. Before that time sporadic efforts were made in various places. The report of the national commission on physical deterioration brought the issue of medical inspection of schools to the front in 1907 when a compulsory law was enacted. Of the English system Hoag and Terman declare that "no other nation unless it be Japan has adopted a school medical service with a more rational conception of its true pur- pose." In her chain of medical clinics England has boldly "undertaken the free medical treatment of her ailing children." Japan has had regular inspection by school physicians since 1898 and their reports show a comprehensive idea of school health as related to national power. Statistics for 1914-15, published by the minister of state for education, showed that 16,040 schools out of 20,208 -had a doctor in regular attendance. That year 2,280,949 children were ex- amined for physical constitution, spinal curvature and eyesight. Full statistics in the report indicate that 52.8 per cent of males and 47.8 per cent of females had good constitutions; 43.7 per cent of males and 48 per cent of females had medium constitutions and 3.4 per cent of males and 4.1 per cent of females had weak constitutions. It is also shown that 2,.^ per cent of males and 4.5 per cent of females had spinal curvature, and that 18.3 per cent of males and 11.4 per cent of females had defective eyesight. France was one of the earlier countries to begin medical inspection and had a partial system in operation by 1886. The French have specialized on school feeding and vacation colonies but have not made comprehensive physical examinations. In Germany the separate states make provision for physical ex- amination, but school doctors are almost everywhere provided. The special feature of the German system has been the dental clinics and open air schools which have also been developed extensively elsewhere. The system in general is not as extensive as the English and is not uni- versal throughout the Empire. In America medical inspection began in Boston in 1894; Chicago, 189s ; New York; 1897 and Philadelphia, 1898. Ohio cities made slight progress until 1910 when Cleveland began the work. At present only half the cities in Ohio have medical supervision and much of this is in the experimental stage. The country as a whole has moved rapidly in the last ten years and now there are more than 800 cities and towns hav- ing medical inspection. In the rural districts of the country very little has been done, except in Pennsylvania where a comprehensive rural sys- tem is in operation. The first development in America was to have school doctors primar- 42 ily to fight contagious diseases. Those who began the work soon saw the astonishing prevalence of physical defects and, realizing the necessi- ty for more complete knowledge of the subject, sought to introduce physical examinations for all children. The mere record of defects was of a questionable value ; the next step was to get defects corrected. A system of reporting the findings to parents was adopted. In some in- stances this secured action but in most cases reports were not followed up because of expense or chronic fear. The next step was the employment of school nurses to assist the doctors, make inspections, give health talks and form the connecting link with the parents in securing the necessary medical treatment through family physicians or the public clinics and dispensaries. The first school nurse was employed in New York in 1902. Since then the employment of school nurses has increased rapidly and today there is no record of the hundreds working in every progressive city of the country. The school nurse is such a necessary part of the machinery that the system has developed spontaneously. The State Superintendent of Public Instruction in cooperation with the Commission, gathered information concerning the status of medical inspection of schools in Ohio. An inquiry was sent to all city and ex- empted village schools and to each county superintendent. Statistics thus gathered showed that of 85 city and exempted village schools report- ing, 54 had some kind of medical inspection. Of these, 27 were only slight beginnings, scarcely amounting to more than inspection for the prevention of contagious diseases. Sixteen cities had one or more school nurses, 14 had a part time physician and 10 had full time physicians. The rural districts showed only a slight beginning in health supervision. Seventeen counties reported some work. No county reported a com- prehensive system in force. No county had a physician either part time or full time. Seventeen counties, however, had school nurses; of these 13 had only the part time service of a visiting nurse. Dental inspection was found in 42 cities. Two cities have made con- siderable progress in this line. Many cities and counties have a cursory inspection made and get a fair idea of the extent of defective teeth. Considerable effort has been made to teach children the proper care for their teeth but very little corrective work has been provided outside of three or four cities. Nine counties have an inspection of teeth by the visiting- nurse. Examination of the eyes was reported in 45 cities and 'Villages, but as in the case of the teeth, very little corrective work was done. Only 9 counties had such inspections. Many schools had statistics showing that from 10 per cent to 25 per cent of the children needed glasses. Slight efforts were being made to see that glasses were provided at cost or free of charge to pupils unable to pay for their own. 43 It was apparent from the figures obtained that not over 25 per cent of the school children of Ohio are attending schools where health super- vision is even reasonably adequate. The school men who expressed themselves declared strongly and without exception for the adequate compulsory medical inspection of all school children. It may be said that no other subject meets with such universal approval from school men, public officials and the public gen- erally. The Commission has urgently recommended that immediate legisla- tion be enacted to provide adequately for medical inspection of all school children by physicians and that nursing service be provided for all city and country schools. CHAPTER III NATIONAL VITALITY In an earlier chapter of this report statistics were given to show the extent of physical defectiveness particularly as it relates to babies and youth. We now propose to set forth the status of physical vitality as it relates to the productive period of life. This country has made progress in the reduction of mortality. From 1880 to 1916 the mortality rate in the registration area has been reduced from 19.8 per thousand to 14.0 per thousand. Cities in the registration area have shown a reduction since 1900 of 1B.9 per thousand to 15.0 per thousand in 1916 and the rural districts have decreased from 15.2 per thousand in 1900 to 12.9 per thousand in 1916. The statistics for Ohio as a whole go back only to 1908. The rate appears to have increased since 1909 from 12.9 to 14.4 per thousand in 1916 but this is undoubtedly due to the increased efificiency of the Bureau of Vital Statistics in gather- ing more complete returns. Some surface observers have taken this record of gross mortality reduction considering this as favorable proof of improved mortality and have failed to analyze the real situation. The facts are that while we have made, progress, that progress has not been entirely satisfactory. We have made advances in spots and with some spectacular diseases. We have not gained all along the line and not at all with certain dis- eases. We have decreased infant mortality somewhat but have made little impression upon the death rate in the productive period of life. Mr. Frederick L. Hofifman is quoted by the National Conservation Commission as follows:^ There is, of course, no question whatever that the American death rate, using the term in a very comprehensive sense, has substantially declined within the last fifty years but it is equally evident that this decline has been at the younger ages and not during the period of life which, economically, is of the greatest value. There is no doubt that the mortality of adult ages is still decidedly ex- cessive. The trend of American mortality for the country as a whole is best shown by the following table, in the absence of mortality rates by age groups covering a period of years. This table, compiled from United States census figures, shows what percentages of all the deaths in the ' National Conservation Commission, National Vitality, Its Wastes and Con- servation, Senate Document 676, 60th Congress, 2nd Session, p. 26. (44) ^0 registration area occurred in each age group in successive years from 1900 to 1915.^ Thus in 1900, 30.4 per cent of all deaths in the registra- tion area occurred among children under 5 years; 7.3 per cent, among young people 5 to 19; 17.7 per cent among adults 20 to 39; etc. Per Cent Distribution of Deaths at Certain Age Periods for the Registration Area, igoo to 1915. Per cent of deaths at al 1 ages (exclusive of stillbirths) Year Annual ^ death rate Under 5 to 20 to 40 to 60 to 80 and Unknown (per 1000 5 19 39 59 79 over population 1900.. 17.6 30.4 7.8 17.7 17.6 20.6 6.1 0.4 1901.. 16.5 27.3 7.0 18.2 18.8 I 21.8 €.5 0.4 1902.. 15.9 28.2 7.0 18.1 18.7 21.4 6.2 0.4 1903.. 16.0 26.7 7.1 18.3 19.0 22.0 6.4 0.4 1904.. 16.5 26.5 7.0 18.2 19.2 22.4 6.5 0.3 1905.. 16.0 27.0 6.8 17.9 19.2 22.5 6.5 0.2 1906. . 15.7 28.4 6.6 17.4 18.7 22.1 6.4 0.3 1907.. 16.0 26.7 6.4 17.5 19.2 23.1 6.9 0.2 1908.. 14.8 27.5 6.5 16.8 19.2 23.1 7.0 0.1 1909.. 14.4 26.8 6.1 16.4 19.1 24.2 7.3 0.1 1910.. 15.0 27.0 6.1 16.3 19.2 23.9 7.4 0.1 1911.. 14.2 25.0 6.1 16.6 19.6 24.7 7.6 0.1 1912.. 13.9 24.4 5.8 16.2 20.1 25.4 7.8 0.1 1913.. 14.1 25.3 6.1 16.1 20.0 24.8 7.6 0.2 1914. . 13.6 23.8 5.9 16.1 20.4 25.7 7.8 0.1 1915. . 13.5 22.4 5.7 16.0 20.8 26.8 8.2 0.1 It will be observed that the percentage of total deaths occurring in children under 5 decreased from 30.4 per cent in 1900 to 22.4 per cent in 1915, while the percentage of deaths occurring among adults of 40-59 increased during the same period from 17.6, per cent to 20.8 per cent. In other words children form a smaller proportion of those dying; adults a larger proportion. This change in the percentage distribution . of deaths may be regarded as an index of two facts; (i) lessened infant ■mortality and (2) higher mortality among adults. 'The slight changes in the age composition of the population are insufficient to account for the change in the percentage distribution of deaths among the various age groups. 46 Indications of a similar trend of mortality in Ohio appear in the following table, compiled from United States census mortality reports^ Per Cent Distribution of D eaths at Certain Age Periods for Ohio, 1909 to 1915. Per cent of deaths at all ages (exclusive of stillbirths) Year Annual death rate Under 5 to 20 to 40 to * 60 to 80 and Unknown per lOOO 5 19 30 59 79 over population 1909.. 12.9 23.1 6.0 15.4 18.3 27.8 9.6 0.1 1910.. 13.7 13.1 24.4 21.5 5. '8 6.0 15.2 15.7 17.8 18.7 27.8 28.2 9.2 9.5 1911.. 1912.. 13.4 21.6 6.0 14.9 18.8 28.7 9.9 1913.. 13.8 22.9 5.8 15.1 18.9 28.0 9.2 1914.. 13.0 20.7 5.5 14.8 19.4 29.7 9.7 1915.. 13.0 19.8 5.2 14.5 19.5 30.6 10.2 ' Less than one-tenth of one per cent. The improved mortality among infants and children and the less favorable mortality among adults is shown with much more exactness in terms of mortality rates and expectancy of life. In the absence of such figures for the country as a whole, the change in the expectation of life in Massachusetts, one of the first two states to be included in the regis- tration area, is of special interest. Expectation of Life in Massachusetts, 757.7 io 1910. Males Females 1877 to 1882 1 1893 to 1897 2 1910 3 Increase or decrease in expectation of. life, 1877 to 1910 1877 to 1882 1 1893 to 1897 2 1910 3 Increase or decrease in expectation of life, 1877 to 1910 1 ■2 3 4 5 10 15 20 41.74 49.84 52.17 52.76 52.93 52.78 49.92 45.86 42.17 44.09 52.18 53.46 53.54 53.30 52.88 49.33 45.07 41.20 49.33 56.12 56.75 56.43 55.90 55.20 51.14 46.71 42.48 +7.59 +6.28 +4.58 --3.67 --2.97 --2.42 +1.22 -0.85 --0.31 43.50 50.24 52.35 52.89 53.00 52.88 50.04 46.08 42.78 46.61 53.58 54.79 54.83 54.62 54.17 50.70 46.53 42.79 63.06 58.79 59.31 58.95 58.34 57.65 53.56 49.11 44.85 +9.56 --8.55 -6.96 --6. 06 --5.34 -4.77 --3.52 --3. 03 --2. 07 G) 1880 Vol. Xll, Part II, "Mortality and Vital Statistics," U. S. Census, p. 776. '2) Massachusetts State Board of Health, Report No ?o 1898 nr. «99 S9«; :3) U. S. Bureau of the Census, United States ii/. TalL igio^^pp Ki; 47 Expectation o / Life ifi Massachusetts, 1&77 to 1910 — Concli ided Males Females 1877 to 1882 1893 to 1897 1910 3 Increase or decrease in expectation of life, 1877 to 1882 1 1893 to 1897 1910 3 Increase or decrease in expectation of life. ^ 1877 to 1910 1877 to 1910 25 39.04 37.68 38.51. —0.53 39.78 39.29 40.77 +0.99 30 35.68 34.28 34.55 -1.13 36.70 35.85 36.78 +0.08. 35 32.32 30.87 30.72 —1.60 33.63 32.43 32.90 —0.73 40 28.86 27.41 26.97 —1.89- ,30.29 29.00 29.04 —1.25 45 25.41 23.93 23.34 —2.07 26.95 25.54 25.25 —1.70 50 22.02 20.53 19.79 . —2.23 28.50 22.10 - 21.55 —1.95 55 18.63 17.33 16.45 —2.18 20.05 18.81 17.09 —2.06 60 15.60 14.38 13.42 —2.18 16.91 15.74 14.79 —2.12 m 12.57 11.70 10.81 —1.76 13.77 12.90 U.94 -1.83 70 10.32 9.34 8.58 —1.74 11.30 10.36 d.49 -1.81 75 8.08 7.87 6.65 —1.43 8.83 8.29 7.30 -1.53 80 6.86 5.70 5.07 —1.79 7.37 6.56 5.49 —1.88 85 5.63 4.31 3.88 —1.75 5.91 5.07 4.17 —1.74 These figures mean that a boy born in 1877- 1882 might expect to live 41.74 years; while a boy born in 1910, might expect to live 49.33 years or 7.59 years longer than if he had been born in the earlier period. This increased expectancy of life is largely the result of prevention of infant mortality and control of contagious diseases. Among adults the results are quite different. A rnan of fifty living in the period of 1877- 1882 might expect to live 22.02 years longer. A man of fifty in 1910 could expect to live only 19.79 years more or 2.23 years less than if he had lived in the earlier period. Among males this decreased expectancy of life first appears at the age of 25 and is apparent in all the higher age groups. This decreased expectancy of life is the result of higher mor- tality in these age groups. While American mortality rates as a whole compare favorably with those of European countries, our position is not so favorable when the figures are analyzed. It is misleading merely to quote gross figures as Fisher and Fisk point out. The fact that in the United States the general death rate has steadily fallen for the past several decades, a phenomenon common to all civilized countries, is accepted by many as evidence of a steady gain in national vitality. That there has been a gain in vitality in the younger age groups is unquestionably true, but this gain has served to mask a loss in vitality at the older age periods. This latter phenomenon, a rising mortality in elderly life, is something almost peculiar to the United States. It is not exhibited in the mortality statistics of the leading European countries. In those countries the fall in the death rate has not been due solely to a reduction oi mortality in infancy and early adult life through tthe conquest of diseases of children, tuberculosis and other com- 48 municable diseases. England and Wales, Denmark, Norway, Sweden and Prussia show improved mortality at every age period.^ / Vital statistics for these countries show that mortality has decreased over a period of years in every age group, and not in the American fashion among the younger age groups alone. The table for Prussia^ shows that instead of an increasing mortality among males beginning at 25 the mortality of males 25-30 has decreased 38 per cent in the period 1875-1880 to 1901-1910. Similarly England and Wales exhibit a de- creasing death rate in every age group.' The same decrease in death 'Fisher and Fiske, How to Live, 1917, p. 281. "Death Rates per 1,000 in Prussia by Age Groups, 1875-1880 to 1901-1910. [Fisher and Fisk, Hov> to Live, 1917, p. 290.1 Sex and year 2-3 3-5 5-10 26-30 30-40 40-60 70-80 and over Male 1875 to 1880. 1881 to 1890. 1891 to 1900, 1901 to 1910. Female 1876 to 1880. 1881 to 1890. 1891 to 1900. 1901 to 1910. 71.8 70.2 58.0 45.3 69.1 «8.0 55.6 43.1 37.1 36.3 24.7 16.5 36.1 34.3 23.8 16.0 22.2 20.8 14.2 21.7 20.7 13.9 9.3 8.8 6.9 4.2 9.2 9.0 0.1 4.4 2.9 2.4 4.3 4.3 2.7 6.1 4.8 4.3 4.0 4.6 4.5 7, 7.0 6.0 6.2 6.3 6.8 6.1 4.6 7 6.1 6.3 8.2 7.6 6.1 5.5 10.9 10.6 8.3 7.0 10.3 9.7 7.9 6.7 16.7 18.3 14.3 12.6 12.3 11.7 10.0 8.6 27.6 26.9 24.2 23.6 20.7 19.8 17.6 16.0 63.0 51.4 48. 45.6 46.3 44.8 42.0 37.4 113.3 110.2 102.5 100.6 106.2 113.9 97.1 102.0 236.4 233.2 233.1 214.4 227.2 2.9.0 223.3 202.0 'England and Wales: Death Rates per 1,000 Persons at Specified Ages, ISil-iS to 1906-10. [Fisher and Fisk, How to Live, 1917, p. 287.] Year 1841-45 1846-50 1861-66 1856-60 1861-65 1866-70 1871-75 , 1876-80 1881-85 , 1886-90 , 1891-95 , 1896-1900 1901-05 , 1906-10 , 0-6 I 5-10 ■8.7 9.4 8.4 7.6 6.9 6.1 5.7 4.9 4.6 4.1 3.7 3.4 10-16 5.0 6.6 5.2 4.7 4.7 4.3 4.0 3.6 3.2 2.8 2.6 2.4 2.2 2.0 7.2 7.7 7.4 6.7 6.6 6.2 6.8 4.9 4.6 4.1 4.0 3.6 3.1 2.9 9.0 8.3 8.4 8.0 7.7 6.5 6.0 6.3 5.0 4.5 4.0 25-30 9.7 10.9 10.1 9.4 8.4 S.O 7.2 6.8 6.0 5.4 4.8 12.1 13.6 12.7 12.0 12.6 12.9 13.1 12.3 11.8 11.1 Jl.O 10.1 8.9 7.8 46-65 16.1 18.1 17.2 16.1 17.1 17.6 18.0 17.6 17.2 17.1 17.3 16.2 14.9 13.7 28.7 31.4 29.6 28.4 31.6 31.6 31.0 31.8 32.6 30.5 28.7 27.6 65-76 62.0 65.9 62.9 60.9 62.4 63.2 66.3 64.7 63.6 63.3 67.3 64.1 59.4 68.1 76-85 137.1 145.8 143.2 136.6 133.x 141.7 141.6 142.9 136.1 139.0 140.8 133.6 127.8 127.0 85 and over 295.3 36.6 299.5 293.4 298.8 294.3 306.2 311. 6 277.7 290.3 274.1 267.5 258.6 262.4 49 rates in all age groups is found in Sweden^ and Denmark.^ Morevore as matters now .stand a man of 20 to 50 in England has before him a longer life than in the United States. The next table indicates this with the precision of actuarial science.^ ^ Death Rates per 1,000 by Age Groups in Sweden, lSOl-1810 to 1891-1900. [Fisher and Fisk, How to Live, 1917, p. 292.] Year 0-5 5-10 10-15 15-26 25-35 36-46 45-56 66-65 65 and over 1801-10 79.0 76.0 63.1 60.3 66.8 60.5 57.3 62.3 43.6 36.9 12.1 9.7 7.6 7.6 7.8 10.9 9.1 8.6 7.7 6.0 7.2 5.6 4.5 4.7 4.4 5.5 4.4 4.2 4.0 3.6 8.6 7.2 .6.1 6.0 5.6 6.1 5.4 5.3 5.2 6.4 11.0 9.9 9.4 9.8 8.0 8.4 7.2 7.4 6.6 6.5 14.9 14.3 13.6 14.3 12.2 11.9 10.1 9.3 8.2 7.8 22.7 21.0 20.1 20.8 18.1 17.9 16.1 13.1 11.5 10.9 40.8 37.6 36.4 36.6 31.8 32. 1 28.7 23.6 21.1 19.7 111.4 1811-20 102.9 1821-30 96.9 1831-40 102 1 1841-50 97.1 1S51-60 91.6 1861-70 87.2 1871-80 79.4 1881-90 .^ . . 71.4 1891-1900 71.3 '- Death Rates per 1,000 by Age Groups in Denmark, 1SS0-S9 to 1890-1900. [Fisher and Fiske, How to Live, 1917, p. 291.] Males Females Ages 1880-1889 1890-1900 1880-1889 1890-1900 0-6 53.1 7.2 4.4 4.9 7.0 6.5 6.8 7.8 9.8 12.6 16.8 22.6 33.3 46.9 70.0 104.9 178.7 246.7 392.3 48.6 6.6 3.6 4.6 6.0 6.6 6.1 7.7 9.3 11.6 15.7 22.0 30.7 44.7 74.5 115.0 169.4 250.1 425.6 46.0 7.7 5.6 5.8 6.1 7.4 7.9 8.4 9.3 10.2 12.2 17.0 26.1 39.2 58.3 92.9 167.4 210.9 350.1 40 8 6-10 6 10 15 4 6 16-20 4 7 20-26 4 9 26 30 6 6 30-35 6 5 35-40 7.6 40-46 ; 8.2 45-60 9.1 60-66 11 8 55-60 16.4 60-65 24 2 65-70 36 7 70-75 es.o 75-80 93.9 80-86 161.6 85-90 226.6 373.2 ' Fisher and Fisk, How to Live, 1917, p. 290. €~'\r-^ ^^ '-■ -i-:! 50 Comparison of Expectations of Life, New York City, England and Wales, London and the Original United States Registration States. Ages New York City, 1909-1911 England and Wales, 1910-1912 London 1911-1912 United States Original Regis- tration States, 1910 Males Females Males Females Males Females Males Females At birth.... 44.65 46.95 38.26 30.34 23.34 17.11 11.71 7.66 4.66 48.8 50.4 41.7 33.6 26.2 19.1 12.9 8.2 4.9 51.50 63.08 44.21 35.81 27.74 20.29 13.78 8.63 4.90 55.35 55.91 47.10 38.54 30.30 22.51 15.48 9.58 5.49 10 51.07 42.48 34.70 27.32 20.32 13.96 8.83 5.10 53.31 20 42.35 33.87 26.03: 19.09 13.09 8.17 4.79 ■ 46.71 37.94 29.67 22.17 15.39 9.57 5.39 44 66 30 36 79 40 1 29 15 50 21 67 60 14 90 70 80 ..' 9.38 5 37 The meaning of this is simply that around 1910 at 30 years of age the American man could expect an average life of 34.70 years ; the New York City man, 30.34; the London man, 33.87 years; and the man of England and Wales, 35.81 years. Ohio people have approximately the same expectation as the people of the whole country. The expectation of life in the original fegistration states varies in different groups. For example the expectation of life for the same sex is greater in rural districts than in cities and is greater among the native whites than among foreign-born whites. An analysis of death rates for the foreign-born residing in New York State showed that the mortality of all the foreign-born and particularly that of certain nationalities, such as the Austro-Hungarian, British, German and Irish was higher than that of the native-born of native parentage. These figures appear below : 51 Deaths per i,ooo Population in. New York State among Persons Born in Germany; in England, Scotland and Wales; and among Native-born of Native Parents, by Sex and by Age Period, ipio.' Age periods German born English and Scotch born Native-born of native parents Males Females Males Females Males Females All ages: Crude rate 27.5 17.9 12.7 , 5.8 3.4 4.5 10.0 27.7 90.4 263.4 22.6 14.4 10.3 1.6 2.7 4.0 6.3 18.4 83.1 246.4 21.8 16.6 7.0 3.7 5.8 4.3 8.7 24.6 86.6 261.9 20.6 15.8 6.0 3.3 5.8 3.8 7.6 21.0 74.9 279.6 15.9 13.8 '23.5 2.5 3.6 5.0 6.9 18.8 77.3 268.9 13.9 Ages 10 and over : Standardized rate . . . Under 10 12.4 19.6 10-14 2.6 15-19 3.2 20-24 4.7 25-44 5.7 45-64 14.3 65-84 68.2 85 and over 242.3 The mortality of these groups of foreign-born is in excess not only of the native-born of native parents but also is in excess of the lower rates in their own native lands. It is pointed out that of the Austro- Hungarian, British, German and Irish : The first appears to be the only one whose mortality in New York State is more favorable than that prevailing in the native country. . . Apparently it is the very high incidence of pulmonary tuberculosis that is largely responsible for this condition, although the degenerative diseases also present rates much in excess of those for the native-born of native parentage or for the same nationali- ties abroad. These facts are clearly indicative .of unfavorable conditions of life and work among the peoples in question.^ The cause of the American phenomenon of increased mortality which affects even the foreigners coming to our shores and lessens the expec- tation of life in the middle age groups in generally attributed to the in- creased death rates from degenerative diseases, such as diseases of the circulatory and nervous systems and of the genito-urinary tract. The increasing death rate from these diseases is made clear in Dublin's well- known table presented to the American Public Health Association in 1913.^ 'Louis I. Dublin, "Factors in American Mortality", American Economic Review, September 1916, pp. 536, 546, 548. "Louis I. Dublin, "Possibilities of Reducing Mortality at the Higher Age Groups," Affierican Journal of Public Health, December 1913, p. 1264. 52 Death Rate per 100,000 Population for Certain Causes of Death, Male and Female Combined. {Registration States as Constituted in 1900.) Cause of death 1900 1910 Per cent increase Cancer — all forms . 63.5 11.0 72.5 116.0 5.2 12.6 81.0 82.9 17.6 86.1 161.6 25.8 14.4 95.7 30.6 Diabetes 60.0 Cerebral hemorrhage and apoplexy 18.8 Organic diseases of heart 39.3 Diseases of arteries 396.2 Cirrhosis of liver 14.3 Bright's disease 18.1 Total 361.8 484.1 33.8 In Ohio these so-called degenerative diseases in 1916 were responsible for a little over one-third (35.2 per cent) of the annual deaths. THE PREVALENCE OF POOR HEALTH The report of the National Conservation Commission on National Vitality in 1909 declared that it is rare to find a person past forty-five years of age who is in perfect health. This broad indication of ill health is backed up by many studies of groups of workers since that time. In an intensive physical examination of garment workers in New York City, made by the United States PubHc Health Service in 1914-15, it was found that among 2,086 males examined, there were present 9,541 defects and diseases, or an average of 4.57 for each rnale. The examina- tion of 1,000 females showed 3,916 defects and diseases, or 4.33 for each female. Among the more frequent and significant defects were the fol- lowing: chronic constipation affecting 22.3 per cent of the men and 26.8 per cent of the women; pyorrhea alveolaris, men 25.7 per cent, women 15.8 per cent; defective posture, 27.9 per cent men and 11.4 per cent women; defective vision, men 68.2 per cent, women 74.1 per cent; flat and weak feet, men 28.7 per cent, women 20.8 per cent; hypertrophy of tonsils, men 12.8 per cent, women 20.4 per cent; dysmenorrhea, women 20.2 per cent ; pharyngitis and nasopharyngitis, men 18.2 per cent, women 9.9 per cent; rhinitis, atrophic and hypertrophic, men 29.3 per cent, women 19.8 per cent, and spinal curvature, men 50.3 per cent, women 20.5 per cent. Active tuberculosis was found in 3.1 1 per cent of the men and 1.2 per cent of the women. This rate, in the case of men, was ten times that of the American army, and in the case of women was three times the army rate. Tuberculosis among garment workers, moreover, was most prevalent among those earning the lowest wages and having the greatest number of persons dependent upon them. 53 Several examinations to determine the extent of tuberculosis among industrial workers have been made. Dr. Harry E. Mock states that an examination of 32,289 employees of the Sears-Roebuck and Co., during a period of five years showed 282 cases of tuberculosis, or less than i per cent (0.87 per cent). Dr. James A. Britton reported 0.88 per cent of tuberculosis cases among 20,000 employes of the International Harvester Co. The most significant investigation for Ohio was made in Cincinnati in 191 5 by the United States Public Health Service. Surgeons D. E. Robinson and J. G. Wilson made an intensive study of 19,932 workers in 38 distinct industries including industries which are hazardous in this respect and those which are not, with a total of 154 work places.^ A total of 220 cases of tuberculosis was found, or i.i per cent. Males showed a percentage of 1.07 and females 1.19.^ These rates covering a wide range of occupations can be considered fairly representative of industrial workers as a whole. An examination of 442 cases of tuberculosis in Cincinnati and a study of their predisposing causes by Drs. Robinson and Wilson showed the results in the following table.' Number of cases of tuberculosis in- vestigated Predisposing causes most in evidence Per cent distribution Cases in which there was a history of tuberculosis in family Cases in which poverty and poor housing were most in evidence . . . . ; Cases in which alcoholism, venereal diseases and ex- cesses were most in evidence Cases in which other diseases and injuries were most in evidence Cases in which occupation, hazard or working condi- tions were most in evidence Cases in which none of the foregoing factors were in special evidence ■ Total It will be observed that industry is charged with 18.1 per cent of the cases; personal vice with 10.8 per cent; heredity with 32.4 per cent; 'Robinson- and Wilson, "Tuberculosis Among Industrial Workers," Pttblic Health Bulletin, No. 73. 'Robinson and Wilson, "Tuberculosis Among Industrial Workers", Public Health Bulletin, No. 73, pp. 68, 59. ^Robinson and Wilson, "Tuberculosis" Among Industrial Workers", Public Health Bulletin No. 73, P- HO. 54 ' poverty and housing with 9.7 per cent; other diseases 8.4 per cent and indeterminable 20.6 per cent. Army examinations of men drafted from a still more important source of information. In the State of Ohio, as it has been pointed out, rejections on physical grounds were at the rate of 32.2 per hundred. ESTIMATES OF THE EXTENT OF SICKNESS • One of the earliest estimates of morbidity was made by Farr, the distinguished English statistician. He estimated that for each death there are two persons sick throughout the year. On the basis of 70,000 deaths annually in Ohio there are by Farr's estimates 140,000 people seriously sick every day in the year in Ohio or a total of over 51,000,000 days. This appears excessive. Data as to the extent of sickness from contagious diseases are ob- tainable from reports made by physicians to the State Department of Health. But even these figures do not present the full magnitude of the problem. For example 3,127 cases of typhoid were reported for 1917 whereas the Department of Health estimates upon the basis of mortality that there were 8,938 cases in 1917.^ Ohio's five years' record appears below : Diseases. 1913 1914 1915 1916 1917 Chickenpox Diphtheria '. Gonorrhea Measles German measles Meningitis Mumps Ophthalmia neonatorum Pneumonia Infantile paralysis Scarlet fever Smallpox Syphilis Trachoma Tuberculosis Typhoid fever Whooping cough 5,570 12,122 6,991 9,621 29,106 "'■376' 16,191 ""'26i' 260 776' 9,511 8,962 2,649 19,388 1,117 187 6,082 125 7,363 2,633 63 7,526 4,789 144 2,922 6,863 10,064 537 5,685 4,796 6,302 4.717 466 9,147 3,221 1,061 6,624 4,501 8,536 7,211 8,094 1,701 56,438 841 172 2,193 1,398 4,020 551 10,160 2,184 804 255 6,217 4,596 9,256 9,386 7,935 1,454 27,971 2,624 630 3,594 1,641 4,028 3,554 9,846 5,243 814 884 6,454 3,127 8,725 - . Occupational, (iis^ajse^^^^sD ifquired by law to be reported. But this legislation', the State* Cepartment of Health reports "has proved very much of a failure. Some score or so of cases have been yielded from this scource." ^ Information as to the extent of such diseases is obtain- able only through special investigation. ' Ohio Public Health Journal, May, 1918, pp. 198, 199. 'E. R. Hayhurst, Industrial Health Hazards and Occupational Diseases in Ohio, 1915, p.358. 55 The sickness records of the army prior to the War throw much light on the prevalence of sickness among able-bodied men. In 1913 the non-affective rate was 18.61 per thousand for diseases alone. Each soldier lost 6.79 days on account of sickness. In 1914 the sickness rate was 18.84 per thousand, so that each soldier lost 6.88 days because of sickness. In applying these data to the general adult population, it should be borne in mind that the group consists entirely of males among whom there is .less sickness than among females, and that this group is com- posed of specially picked lives. Moreover complete medical care is given and careful over-sight exercised to prevent malingering. These facts tend to reduce sickness to the minimum. On the other hand, the soldier does not lose his pay while incapacitated (except for venereal disease). Our knowledge of morbidity among the general population has been increased during the past few years by the surveys made by the Metro- politan Life Insurance Co. Surveys among the industrial policy-holders of this company have been made by the agents and have covered Rochester, N. Y., Boston, Mass., Kansas City, Mo., cities of West Vir- ginia, cities of Pennsylvania, North Carolina, Trenton, N. J. and the Chelsea district of New York City. A total of 579,197 white men, women and children were covered and 10,878 were found unable to work, or 18.8 per thousand. A total of 376,573 people over 15 years of age showed 8,636 cases of disabling illness or 22.9 per thousand. The average dis- abling sickness for each of the persons of working age was, therefore, 8.^ l ^davs or 6.Q workin g days per year. When the data for disabling illness are classified according to sex, they show that white males over 15 have a morbidity rate of 22.8 per thousand and white females over 15 have a rate of 23.0 per thousand. These sickness rates represent an average total lo ss of 8.3 days a year for men a nd 8.4 days per year for women. If these rates are applied to the population over 15 m Ohio (3,700,000), it gives an annual total of 31,000,000 sick days and a loss of 25,000,000 working days a year. The United States Commission on Industrial Relations estimated upon the basis of an examination of sickness statistics of more than a million workmen, that each industrial worker loses an average of nine days a year.^ This estimate is approved by Warren and Sydenstricker in their report on health insurance for the United States Public Health Service.^ ^~_^-. Two sickness surveys were mati»Blby':'th:et^ieansylvania Health Insur- ance Commission in 1918. One in Philadelphia covered 12,019 persons and on the day of the survey 514 persons were found to be sick. ..This_ was an average daily sickness rate of 42.8 per thousand. Only 15.7 per thousand, however, were so ill that they were unable to work. This ^ Final Report of the Commission on Industrial Relations, 1915, p. 202. ' Warren and Sydenstricker, "Health Insurance : Its Relation to Public Health", Public Health Bulletin, No. 76, pp. 6, 8B. 56 figure for disabling sickness approximates that obtained by the Metro- politan in its survey of Pennsylvania cities. The second survey of the Pennsylvania commission covered 743 families including 3,198 individ- uals and 1,341 workers and gathered a year's experience. In this sur- vey apparently the trivial cases were not remembered. There were 1,994 cases of sickness reported. The principal wage-earners suffered 527, other wage-earners 319, housewives 466 and all others 677. Thus 1,312 cases or 66.2 per cent directly affected the family's living. Ninety-one families had no disabling sickness; 179 families had one case; 173 had two cases; 162 had three and four cases; 126 had five or more cases. Twenty-six reported ten or more cases. As for the duration 57.6 per cent of the cases lasted less than a month ; 19.2 per cent lasted from one to three months; and 12. i per cent lasted more than a year. The average loss to each wage-earner who was sick was 39 days. The Ohio Commission directed that statistics showing disability among groups of insured workers be gathered. The experience of nine benefit funds covering 663,163 workers and 131,921 cases of disability which lasted eight days and over and which were due to sickness and non-industrial accident was examined. The analysis showed that for every 100 members, there were 19.7 cases of disability lasting eight days and over. The average number of days disability per member per year — based on these cases, exclusive of days of- disability beyond 189 days — was fin days. In the Workmen's Sick and Death Benefit Fund which was analyzed separately, it is estimated upon the basis of compensated cases of disability ^ lasting more than one day — exclusive of days of dis- ability beyond one year — that each member was compensated on the average for ^ 6.9 d ays of disability a year. Since these figures are for compensated cases only and do not include days of disability beyond the specified ranges, they are, therefore, somewhat less than the total sick- ness among the groups studied. B'rom the mass of data all pointing to the same conclusion, the Commission estimates that for the whole group of employed workers in Ohio the average days of sickness will ^be about nine days annually . But the estimate of the average rate of sickness does not tell the story of economic distress caused by sickness nor indicate the insurance problem involved. It does not indicate how the burden falls upon the in- dividuals who are sick. The Commission also directed that statistics be compiled showing the distribution of cases according to duration. Among the 663,163 workers under observation, there were 131,921 cases of disability lasting eight days or over or 19.7 cases for every 100 members. Of the cases last- ing eight days or more, 34.7 per cent lasted from eight to 14 days ; 19.5 per cent lasted from 15 to 21 days; 11.3 per cent lasted from 22 to 28 ' Disability in this instance is inclusive of disability due to industrial accidents. 57 days; 17.9 per cent over one month but less than two months; 6.4 per cent over two months but less than three months; 7.1 per cent over three months but less than six months and 3.1 per cent over six months. The overwhelming evidence of unnecessarily high mortality and preventable ill health point to the plain necessity for special efforts for physical betterment. The national welfare is at stake in this matter "In the health of the people lies the wealth of the nation," said Glad- stone. The events of the past year and a half have amply proven the correctness of that statement. An impressive lesson of what physical efficiency means on the battlefield and in the shop has been given. That lesson must not now go unheeded. "The most valiiable resource of any country," said Professor Thomas Nixon Carver, "is its fund of human energy, that is, the working power, both mental and physical, of its people. It is safe to say that any capable race of men who will conserve, economize and utilize that fund will be able not only to extract a living but actually to prosper in the midst of poor natural surroundings. On the other hand, if they fail to economize their fund of energy, if they waste and dissipate it, they will certainly decay in the midst of the richest geographical and material resources." " '■ Ely, Hess, Leith, Carver, The Foundations of National Prosperity, 1917, p. 275. CHAPTER IV SICKNESS, DEPENDENCY AND ECONOMIC DISTRESS Sickness is so widespread that the Commission directed that special efforts be made to determine its effects on economic well-being. The investigation disclosed that the advent of sickness in many families is the sign for raising the signal of economic distress. The degree of dis- tress varies with financial resources. To those already in poverty, illness of the breadwinner means an intensification of misery; to those who do not feel the pinch of want when all is fair sailing, sickness of the bread- winner may so diminish income and so deplete slender savings, as to plunge the family into poverty ; among those of larger resources, savings may be supplemented by borrowing and credit. In each of these groups, distress is so great that assistance is often sought. The character of the assistance varies with the economic status. Among the ragged ends it may be public relief; among the poor independent wage-earners, char- itable relief ; among those with slightly larger resources, a loan secured by personal property ; amon^g those who have established personal credit, a personal loan. Although these groups are not hard and fast, and are constantly changing, this classification provides a working basis. The Commission has sought to measure the economic distress caused by sick- ness among the various groups. Economic distress is most severe among those living from week to week on current earnings. The results of numerous private and official investigations were well summed up by Frederick Hoffman in 1915 when he stated : ^ It has been said — and I believe it is true — that the majority of our wage- workers have not a single week's wages ahead. Now, if this is true, and if that amounts to $10 or $15, you can see how narrow the margin is between economic dependence and economic independence. It is apparent, therefore, that if a wage-earner is sick for any length of time, the combined results of the cessation of income and increased ex- penditure is to throw the family over-board into dependency upon others. Sidney and Beatrice Webb, who rank among the world's foremost au- thorities on problems of poverty, have declared that:- ' Frederick Hoffman, Journal of the American Medical Association. Decem- ber 11, 1915, p. 2060. ^Sidney and Beatrice Webb, The Preven.tiou of Destitution. 1911, pp. 6, 7 15 (■58-) 59 We find five well-trodden paths along one or other of which the vast majority — we might almost say all — of the three or four millions have gone down in the morass of destitution. At least one-third, of them are sick or pre- maturely broken down in strength and would not be destitute but for their sick- ness or infirmity. Then we have the army of widows with young children on their hands, who have been suddenly plunged into destitution by the premature death of the breadwinner. Of the itotal, indeed, one-third are infants and chil- dren who are destitute not on account of any characteristic of their own, but merely because their parents are dead, or for one reason or other unable or unwilling to fulfill their parental obligations. A large contingent have fallen into destitution merely as the result of the infirmities of old age; whilst another large 'contingent are in the same condition plainly because of their imbecility, lunacy or congenital feeble-mindedness. Finally, we have to recognize the able-bodied person whose destitution comes obviously from his prolonged inability — it may be incapacity or unwillingness — to find sufficient employment at a sufficient rate of pay to pr6vide him and his dependents with the necessaries of life. All these roads run in and out of each other, creating what we may accurately describe as a vicious circle about the morass of destitution. They continue, "In all countries, at all ages, it is sickness to which the greatest bulk of destitution is immediately due." Mr. David Lloyd- George, in opening the debate on the British national insurance act ia 191 1, declared that 30 per cent of the pauperism of England was due to sickness and that "there is a mass of poverty and destitution in this country which is too proud to wear the badge of pauperism and which declines to pin that badge to its children." For the United States the concensus of opinions from all responsible sources is that from 35 per cent to 50 per cent of the poverty which asks for relief is directly due to sickness. As the result of an investigation covering forty-three cities and over 30,000 charity cases, the United States Immigration Commission reported in 1909 that illness of the breadwinner or other member of the family was a factor in 38.3 per cent of the cases seeking aid.^ In New York City "sickness or deformity" were present in two-thirds of the 3,000 families assisted by the Charity Organization Society in the first five months of 1916; in Chicago sick- ness is reported as the primary factor in 25 per cent of the cases cared for in 1917 by the United Charities, and as a contributory factor in 45 per cent of the other cases; in San Francisco and Los Angeles sickness was the primary cause of destitution in 50 per cent of over 5,000 chari- table cases. For Ohio, the investigations made for the Commission show that sickness is the leading cause of dependency. In Cleveland, the Asso- ciated Charities reports that in 1917, 51 per cent of their cases were due to sickness; Columbus reports 25 per cent of the applications are due directly to sickness arid that sickness is present in 74 per cent of cases; Newark, 36 per cent; Springfield, 30 per cent and Toledo, 35 per cent. 'United States, Report of the Immigration Commission, 1909, Senate Docu- ment 665, 61st Congress, 3rd Session, Vol. 34, p. 333. 6o In Cleveland, an examination covering a three year. period of the Asso- ciated Charities' records was made for the purpose of determining the proportion of disability, other than that due to industrial accident, present among those applying the first time for relief. The results showed that out of 6,272 cases seeking relief for the first time, disability was present in 2,112 or 33.7 per cent. The tragedy is that large numbers of normally self-supporting and independent wage-earners are reduced to poverty and dependency by sickness. For example, among 500 families aided by public charity in California, there were many whose breadwinner had been earning con- siderably more than the average wage, but who had been obliged to ask for help because the savings of years had been expended for medical and living expenses. "^ Among the persons admitted to county infirmaries in Ohio, in which 60 per cent of the regular inmates are 60 years of age or over, sickness again is a leading cause of dependency. Ohio infirmaries it should be borne in mind are the institutions commonly referred to as "almshouses," "poorhouses" or "workhouses," and are equipped to furnish only the most meager medical care. Infirmaries are not primarily hospitals but serve as a refuge for the destitute. Among 7,867 inmates the character of whose principal disability was reported to the Board of State Chari- ties, sickness, disease or loss of member was returned for 27.8 per cent of these inmates and old age for 47.7 per cent. Among a group of 1,608 inmates studied by an investigator for the Commission, disease, sickness or accident was the cause of dependency for 482 or 30.0 per cent and intemperance for 468 or 29.1 per cent. In other words, in the group which is often said to represent the lowest ranks of society, illness is a leading cause of dependency, second only to old age. Dependent old age, the Comtnission's investigators find, is frequently attributable to sickness. A study of 500 aged inmates cared for in private institutions for the aged in Ohio reveals that in 204 cases or 40.8 per cent disease and sickness were the leading causes of dependency. This was followed by misfortune and intemperance, responsible respectively for 19.6 per cent and 12.0 per cent. Notwithstanding the very different strata covered by this survey, a difiference apparent from the smaller proportion of dependency due to intemperance, sickness still retains its place as the chief cause of dependency. The old age problem itself, the Hamilton investigation discloses, is not infrequently a sickness problem. Among men over 50 years of age studied in Hamilton, sickness was the most frequent cause for retire- ment, accounting for 61 of the 87 retirements. When the retired are classified by age groups, 40 of the 61 retirements due to sickness occurred in the age period of 50 to 64. Of the 26 who retired on account of old ^Report of the Social Insurance Commission of the State of California, 1917 p. 52. 6i age, only one man retired before 65. Among a group of 81 men who had been obHged to seek Hghter work, sickness was the most frequent reason for change given, accounting for 49 of 81 changes. Forty-eight out of 49 changes due to sickness were among men in the lower age groups of 50 to 64. In other words sickness is the most potent cause of premature old age. Poverty, as distinguished from dependency, is frequently a cause of sickness. That is to say, chronic need, which is the badge of those whom we term "poor," breeds ill health and disease. Low wages, wages some- times irregular in amount or time of payment, absolute cessation of earnings when the bread winner ceases work either because of illness or because he is no longer needed, engender want. "Want" may take the form of insufficient or unsuitable food, insufficient protective cloth- ing, inadequate housing or lack of necessarj^ sanitary facilities. On every side there are evidences that chronic want and disease are close partners. Perhaps the most important testimony is the lowered sick rate during the war among the 14,000,000 persons insured under the British in- surance act, shown in the following figures. ' Average Expenditure on Sickness Benefit in Pence per Week under British National Health Insurance, igis-1916^ Year Men Women 1913 d. 2.16 2.43 2.22 2.06 d. 2.46 1914 2.87 1915 1.84 1916 1.56 This change, the official report points out, is due in part to the small amount of unemployment, the rising wages and consequent better living conditions during the war.^ The relationship between poverty, sickness and dependency is this. Prolonged illness among those living just within their income is an economic disaster. Among those of slender income and meager re- sources of savings, of credit or of friends, sickness causes poverty. Among those living constantly in want, poverty causes sickness; sick- ness aggravates poverty and so on in an endless chain. If poverty and its attendant conditions cannot be abolished, sickness can be prevented and systematic provision can be made to provide for the economic crisis occurring when sickness eludes the public health official. Only so can ' Great Britain, Report on the Administration of National Health Insurance during the Years 1914-1917 , Cd. 8890, 1917, pp. 11, 12. 62 this endless procession of siclears below. Family Expenses for Sickness Among 211 Families in Columbus during the Year ending August 31, igiS^ Amount Expended Physician Surgeon Oculist Medi- cine Nurse Hos- pital Den- tist Eye Glasses Other Health Purposes No expenses . . . Less than $10... 10-19 20 48 39 34 29 13 14 4 5 164 32 6 2 i" 174 6 14 6 4 2 1 3 i 190 3 3 4 1 1 2 2 3 2 104 54 37 9 3 1 160 35 13: 3 208 3 20-29 30 39 40-49 50-59 . . ../.... 60-69 1 1 1 70-79 80-89 90-99 3 3 2 100-124 125-149 1 150-174 175-199 200-249 2 250-300 Over 800 J 'Unpublished material of the United States Bureau of Labor Statistics, Cost of Livinfi in Columbus for the year ending August 31, igi8. The average expenditure for physicians', surgeons' and ocuhsts' fees among this group was $24.99 : for medicines, $6.82 ; for nursing, $4.90; for hospital, $3.68; for eyeglasses, $2.02 and for dentistry, $6.00. In Philadelphia and vicinity the expense for medical care is some- what less. Cost of living studies made in Philadelphia and Chester, Pa., by the United States Bureau of Labor Statistics showed an average family expenditure for medical care of $34.91 among 192 families in Philadelphia and $37.90 among 40 families in Chester. The Bureau of Municipal Research of Philadelphia in 1918 studied 260 family budgets and found an expenditure varying from $16.77 per family in the lower income groups to $44.91 in the higher income groups with an average of $32.30 for all families. The increasing outlay for medical care with an increase in the family income is shown clearly in the following table taken from the cost of living study during the year 1916, made by the United States Bureau of Labor Statistics in the District of Columbia. 117 Average Expenditure for Sickness Among ^22 Families, Washington, D. C. for Year of 1916^ Income Families Average expendi- ture Under $600 Total 65 46 19 235 117 118 215 167 48 209 198 11 198 191 7 922 692 230 $12 01 Whites 12 83 Colored . . . . ... 10 03 $600-$900 Total 20 84 Whites 25 52 Colored 16 20 $900-$1200 Totar 40 19 Whites 42 31 Colored 82 84 $r20O-$150O Total 42 42 Whites 43 16 Colored 28 95 $1500 and over Total 58 71 White 59 57 35 21 All incomes 37 75 White 43 59 20 19 • ' The United States Bureau of Labor Statistics, Monthly Review, November, 1917, p. 11. The average expenditi:re of $43.59 among the 692 white families in .ill income groups agrees closely with the average expenditure in Ohio oities. It appears from these figures that the average family of fair income pays out about $42 for medical care. All these studies closely agree in this respect. The average for the poorly paid groups is much less, the Washington study shows that in these groups there is undoubtedly a considerable amount of medical charity from the dispensaries, hospitals and physicians. Taking into consideration the fact that a large part of the population is in the low income group it is a safe estimate to place the average expenditure per family for all families in the state at $30 to $35. There are approximately 1,255,000 famlilies in Ohio with an average of 4.2 persons to each family. The total cost of medical care would therefore amount to from $37,500,000 to $44,000,000 for the entire state. ///. Reduced Earning Power The greater part of loss represented by a reduction in earning power, either partial or complete, is borne almost entirely by the in- dividual. We do not know how much this loss is because we do not ii8 know even the approximate number of persons who are partially c totally incapacitated. But the number is large and the annual loss prol ably exceeds the total wage loss. Some of this loss is borne by the publ in the form of public charity to those made dependent and some is bom by industry in the form of superannuation allowances or in the form c unnecessary jobs created to take care of disabled men. Practically nor of this loss is distributed by insurance. PUBLIC EXPENDITURE The public incurs some expense for treatment and relief of tl sick. The State of Ohio spent $278,315 in 1916 for public, health. Tl cities of Ohio spent $631,945 not including sewage disposal, garbage n moval and street cleaning. Private health agencies, including hospital spent about $10,000,000. The state cares for the m|entally sick peop in eight state hospitals at an expense, in 1916-17, of $2,528,890. Epilej tics are cared for in a state institution at an annual cost of $442,758. state institution for feeble-minded is maintained at an expense of $414 834. The blind received in 1916 $405,077 for pensions from the countii and a state school for the blind was supported at an expense of $103,96 The deaf and dumb have a special state school at an expense of $138,26 Victims of tuberculosis are cared for in county, district and municip; sanatoria and in a state hospital at a total annual cost of $1,000,000 f{ the counties, districts and cities and of $94,587 for the state sanatoriur For the relief of sickness, voluntary charity spends annually in the neigl borhood of $1,000,000. Of the $1,966,352 spent in poor relief in 19] (both for infirmaries and outdoor relief) 30 per cent or $589,935 chargeable to sickness. As an aftermath of sickness the state spent 1916, $493,781 for widows' pensions. The total of these items of publ expense chargeable to sickness is just over $18,000,000. The state has an investment of approximately $20,000,000 in sta institutions for the care of the sick and defective. The counties have £ investment of nearly $10,000,000 in county infirmaries. Public ar private bodies have an investment of $50,000,000 in hospitals and home making a grand total of $80,000,000 of investment, 90 per cent of whi( may be charged directly to sickness and representing an annual intere outlay of more than $3,600,000. The new capital investment annual runs into the millions. There are also some negative losses which are borne by industry ar the community, resulting from the inefficiency of workers due to sicknes These losses fall first upon industry but are in the long run charge to operating expenses and are borne by the consuming public. Tl elimination of such losses redounds to the benefit first of industry at finally of the public. 119 It costs a round sum each year to pay for labor turnover. Estimat'es place the cost of hiring men at $30 to $50 each. Sickness is an important factor in the cost of labor turnover because it attacks the old and steady employees — men who cannot readily 'be spared ■■ — as well as those who drift from plant to plant. Serious disorganization of an industry may take place by reason of the absence of skilled workers, foremen and superintendents. Absences among such workers are quite generally due to sickness and much of the cost of labor turnover in these ranks is chargeable to sickness. We are unable to make any definite estimate of the amount of this item but it is apparently large. The industrial loss from workers whose efficiency is sapped by disease is perhaps im- measurable but nevertheless is a tangible loss. Sick men cannot work with their average efficiency nor produce goods without excessive spoil- age. Another negative loss is that to the state caused by permanently im- paired earning power or needlessly lost lives. The annual toll of death in 1916 in Ohio was 74,230 or 14.41 per 1,000 of population. Each death that terminates a life which possesses potentialities for usefulness constitutes a loss to Ohio and to its in- dustries. Ohio expends money through its school system to train its boys and girls to 'be intelligent and useful citizens. But if a boy or girl dies at fourteen he has had no chance to return through his own services interest on the investment his education represents: In addition the state loses the products which the boy or girl would have contributed during his working years. Upon the basis of cost of rearing, earning power and expectation of life, the average economic value of lives sac- rificed by preventable death has been estimated at $1,700. It has been further estimated that 42 per cent of the deaths annually occurring are postponable.^ At this rate in Ohio 31,000 postponable deaths at an average value of $1,700 for each life lost occurred in 1916, making a total preventable loss to the state of $52,000,000 for the deaths of a single year. THE PRESENT DISTRIBUTION OF THE BURDEN BY INSURANCE The cost of sickness now borne by the state or by industry is but a fraction of that borne by the individuals upon whom the burden falls directly. An investigation has been undertaken for the Commission to discover the extent to which individuals distribute the burden among themselves by insuring against the hazard of sickness. This investi- gation shows that the following health insurance agencies have been de- veloped in Ohio. 'National Conservation Commission, National Vitality, its Wastes and Con- servation, Senate Document 676, 60th Congress, 2nd Session, pp. 728, 741. I20 I. Mutual benefit associations or so-called establishment funds. II. Fraternal sick benefit funds. III. Trade union sick benefit funds. IV. Special sick clubs or associations. V. Commercial health insurance. VI. Industrial or burial insurance. I. Establishment Funds In Ohio there are 150 mutual benefit or establishment funds main- tained by and for the employees of a particular establishment or by the employers for their workers. In the 150 funds in 1917 there were at least 100,000 men insured for a sickness benefit of from $5 to $7 a week, and in a few cases for one-half and even for two-thirds of wages. These funds paid in 191 7 to Ohio members approximately $400,000 for sick- ness benefits or an average of $4 per member, //. Fraternals A consideraJble amount of health insurance is carried by fraternal societies either in national orders or in local lodges. The usual cash payments are from $5 to $7 a week with occasionally a slightly larger benefit. An attempt was made to determine for the Commission the amount of fraternal insurance in Ohio. The orders which provide health insurance from a state or national fund were able to supply accurate information. Questionaires were sent to all local lodges of other fra- ternal orders asking whether they had health insurance, and if so, the numbers covered and the total amou^it paid out during the last fiscal year. The replies were not complete, but from the information received, it is estimated that 593,000 persons carried health insurance through national, state and local fraternal organizations and that $1,403,755 was paid out during the year 1916-1917, or $2.37 per member. Usually medi- cal attendcmce was not provided. An intensive survey was made of Columbus to determine the extent of fraternal sickness insurance in a given community. In this survey it was found that there were 20,739 members of 96 lodges in Columbus. These 96 lodges paid sickness benefits last year amounting to $47,579 or an average of $2.29 for each member. ///. Trade Unions Trade unions carry some sickness insurance for their members either in national organizations or in local unions. The national organizations which are members of the American Federation of Labor paid out in 1917 $668,783 for sickness benefits throughout the United States. We have no basis to determine what portion of this sum was paid to Ohio members but the total probably does not exceed $50,000. From a special 121 inquiry among 67 local trade unions in Columbus, it was found that 23 or approximately one-third had sickness benefits and that 3,438 men or approximately one-third the organized workers of Columbus, were covered by sickness insurance of local unions. Nineteen unions in Columbus reporting payments had an average payment of $2.63 per member for sickness. Upon this basis it is estimated that in Ohio 85,000 union members, including the members of national unions, have some sick benefits from the union, and that not over $250,000 was paid out last year. Special sick clubs are not numerous and the amount paid out for sickness benefits amounts to only a few hundred dollars annually. IV. Commercial Health Insurance The commecial health insurance companies for the year ending June 30, 1917, showed a total of $417,149 collected in Ohio in premiums for health insurance and $177,950 paid out for losses, i. e. sickness benefits. Companies doing a combined sickness and accident business received in Ohio for the same fiscal year $2,877,377 in premiums and paid out $1,211,315 in losses. This represented insurance for sickness and non- industrial accidents, but a large part of this as well as of health insurance was undoubtedly from the professional and employing groups. Summarizing these figures we find that the amount of the sickness burden distributed by insurance in Ohio by health insurance carriers was as follows: Fraternals $1 ,403,750 Trade unions 250,000 Establishment funds 400,000 Commercial insurance companies 177,950 Commercial accident and sickness insurance companies.... 1,211,315 Total $3,443,015 Probably 80 per cent of the sickness and accident insurance in com- mercial comlpanies is carried by professional and non wage-earning people. Deducting this 80 per cent from these two items we find that about $2,331,603 of the wage-earners' loss is carried by insurance. V. Burial Insurance Industrial or burial insurance is provided by insurance companies and a large part of the working men carry one or more policies, cover- ing themselves or members of their families. The premiums are pay- able weekly and are collected by agents from house to house. The amount of the policies is generally only enough to cover the funeral ex- ' Th? Insurance Year Book for 1918, pp. A-334, 335, 122 penses of the insured. In 1917 industrial insurance companies collected in Ohio $12,164,463 in premiums and paid $3,455,059 in death losses.^ Fraternals carry a large amount of life insurance among working- men and a large part of this is in small policies. During 1917 a total of $4,724,478 was paid by fraternals in losses and claims in Ohio.^ Numerous local organizations, including establishment funds and labor unions, pay a death benefit of $50 to $100. There is also consider- able development of group life insurance whereby the employer insures all of his men as a group for amounts based upon length of service. Altogether, approximately $19,000,000 is paid for life insurance in Ohio more than 90 per cent of which is policies which are sufficient to cover only the cost of burial. '■ The Insurance Year Book for 1918, p. 332. ''Ohio Insurance Department, Summary of the Standing December 31, 1917, of all Life Insurance Companies, Fraternai Associations and Assessment Associa- tions authorized to do Business in Ohio, p. 165. CHAPTER VIII THE LIABILITY FOR LOSSES FROM SICKNESS The conclusion from the review of the responsibiHty for sickness on the part of industry, the individual and the community, as set forth in Chapter VI is clear. It is well established in law and morals that where there is responsibility, liability follows. It is entirely reasonable that if the three factors cause sickness, the burden of sickness should be distributed among them in an equitable proportion. THE LIABILITY FOR SICKNESS If that part of sickness which each factor causes could be separated from the rest, then the distribution could be readily made by charging each disease to its proper cause. The full responsibility for some dis- eases can be clearly fixed. Lead poisoning can frequently be directly traced to the industry which uses lead. Typhoid fever can be charged to the community, for it spreads only because of comimunity laxness. The liability for venereal diseases, with some exceptions, can be placed upon the individual. Not so, however, with the great bulk of diseases which cause disability. They spring from a variety of causes and are fostered by conditions over which no one of the factors has entire con- trol and to which two or more of the factors contribute. They cannot be traced to each factor with the exactness necessary to fix a direct liability. The amount of respiratory, circulatory, nervous and degen- erative disease which is caused or aggravated respectively by the individ- ual, by industry or the community is not exactly determinable, but all the evidence by informed people indicates that the responsibility of each factoi- is considerable. The employers' liability and workmen's compensation acts afford a wealth of fact and legal concept for guidance in this new problem of apportioning the cost of sickness. Under common law an employer is liable for damages by accident to his employee while engaged in work, except in the case of injury by a fellow servant, or when the employee contributes to the injury or when the workman assumes the risk of the employment. The growth of industry made these defenses of the em- ployer a practical barrier to recovery of damages by the worker and laws were passed doing away, in part or in whole, with these defenses. The whole system of lability for accidents was based upon the following proposition as stated by the Supreme Court of the United (123) 124 States in upholding the constitutionality of the workmen's compensation act of New York.' Employer and employee, by mutual consent, engage in a common oper- ation intended to be advantageous to both ; the employee is to contribute his per- sonal services, and for these is to receive wages, and, ordinarily, nothing more; the employer is to furnish plant, facilities, organization, capital, credit, is to con- trol and manage the operation, paying the wages and other expenses, disposing of the product at such prices as he can obtain, taking all the profits, if any there be, and, of necessity, bearing the entire losses. In the nature of things, there is more or less of a probability that the employee may lose his life through some accidental injury arising out of the employment, leaving his widow or children deprived of their natural support; or that he may sustain an, injury not mortal, but resulting in his total or partial disablement, temporary or permanent, with corresponding impairment of earning capacity. The physical suffering must be borne by_^the employee alone; the laws of nature prevent this from being evaded or shifted to another, and the statute makes no attempt to afford an equivalent in compensation. But, besides, there is the loss of earning power, — a loss of that which stands to the employee as his capital in trade. This is a loss arising out of the business, and, however, it may be charged up, is an expense of the opera- tions, as truly as the cost of repairing broken machinery or any other expense that ordinarily is paid by the employer. Who is to bear the charge?- It is plain that, on grounds of natural justice, it is not unreasonable for the state, while relieving the employer from responsibility for damages measured by common law standards and payable in cases where he or those for whose conduct be is answer- able are founid to be at fault to require him to contribute a reasonable amount, and according to a reasonable and definite scale, by way of compensation for the loss of earning power incurred in the common enterprise, irrespective of the ques- tion of negligence, instead of leaving the entire loss to rest where it may chance to fall, — that is, upon the injured employee or his dependents. As a result of workmen's compensation legislation the employer who under the common law and by legislative enactment, had been liable for a large part of the serious accidents, became liable for practically all accidents and in turn was allowed to settle for all accidents on a fixed scale. The employee, in return for the fixed scale of damages to be paid automatically, gave up his right to sue for such damages as he saw fit. All the burden of cash benefits and medical care was placed on industry. The United States Supreme Court in the same case states i'- The pecuniary loss resulting from the employee's death or disablement must fall somewhere. It results from something done in the course of an operation from which the employer expects to derive a profit. In excluding the question of fault as a cause of the injury, the act in effect disregards the proximate' cause and looks to one more remote, — the primary cause, as it may be deemed, — and that is, the employment itself. For this, both parties are responsible, since they voluntarily engage in it as coadyenturers, with personal injury to the em- ployee as a probable and foreseen result. In ignoring any possible negligence of the employee producing or contributing to the injury, the lawmaker reason- ably may have been influenced by the belief that, in modern industry, the utmost •diligence in the employer's service is in some degree inconsistent with adequate ' N. Y. C R. Co. vs. White, 37 Sup. Ct. Rep, 253, 254. 1^5 care on the part of the employee for his own safety; that the more intently he devotes himself to the work, the less he can take precautions for his own seclirity. And it is evident that the consequences of a disabling or fatal injury are pre- cisely the same lo the parties immediately affected, and to the community, whether the proximate cause be culpable or innocent. Viewing the entire matter, it can- not be pronounced arbitrary and unreasonable for the state to impose upon the employer the absolute duty of making a moderate and definite compensation in money to every disabled employee, or, in case of his death, to those who are entitled to look to him for support, in lieu of the common law liability confined to cases of negligence. When we approach the problem of fixing a liability for sickness, the principles established in employers' liability and workmen's compen- sation laws stand out as guides. If sickness were caused entirely by industry and the cause were traceable to a given plant, the workman could doubtless recover damages under the common law. Certainly a statute law which would fix such a liability would be upheld. These statements apply equally to the community and its relative responsibility and liability. The fact that it is extremely difficult to fix the responsibility for a particular disease upon a specified industry, plant or process, or to establish the relation of a given case to a community hazard, accounts for the fact that damage suits have not succeeded in bringing about the same results as in the case of accidents. Experience under a law attempt- ing to fix the liability for sickness upon industry or the community, would establish the difference between the problem of fixing responsi- bility for sickness and the problem of determining responsibility for in- dustrial accidents accomplished under workmen's compensation. The inclusion of specific occupational diseases under compensation laws as in Massachusetts, California and under the United State workmen's com- pensation act is sufficient to establish the precedent that insurance is a means of distributing the liability for sickness equitably after the re- sponsibility has been recognized. The intermixture of causes for all but a very few cases of sickness makes it plainly impracticable to settle the liability problem by the passage of sickness liability laws. The number of diseases which can be traced to their exact source and which have no contributing cause from- one or both of the other factors are insignificant. The problem can be solved only by apportioning the total cost of sickness among the three causative factors in some proportion which bears a reasonable relation to the responsibility of each. That each should bear part of the burden is a conclusion from which no reasonable dissent can be made. What the part of each should be, is a matter to be decided with justice and fairness after carefully surveying the health hazards for which each is responsible. Undoubtedly, experience will modify from time to time the conclusions reached, but the principles of justice are satisfied if an effort is made to 126 apportion the burden reasonably and if the way is left open for such adjustments as experience may dictate. The application of experience rating would relieve the system of any permanent unfairness. It is contended that it is unfair to place the burden of sickness alike upon the careful humane employer and the. careless, indifferent employer ■ — upon the employer who provides good working conditions, short hours and recreation as well as upon the employer who does not provide health- ful working conditions, a living wage or means of physical improve- ment. If this argument is tenable in the case of sickness, it is tenable in the case of accidents. There were humane and careful employers, as well as careless and inhumane employers before the workmen's compen- sation laws were passed. Yet all alike were subjected to assessments for insurance. The Supreme Court of the United States, speaking on this very point in the Washington case, said :^ To the criticism that carefully managed plants are in effect required to contribute to make good the losses arising through the negligence of their com- petitors, it is sufficient to say that the act recognizes that no management, how- ever careful, can afford immunity from personal injuries to employees in the hazardous occupations, and prescribes that negligence is not to be determinative of the question of the responsibility of the employer or the industry. Taking the fact that accidental injuries are inevitable, in connection with the impossibility of fore- seeing when, or in what particular plant or industry, they will occur, we deem that the state acted within it^ power in declaring that no employer should con- duct such an industry without making stated and fairly apportioned contributions adequate to maintain a public fund for indemnifying injured employees and the dependents of those killed, irrespective of the particular plant in which the acci- dent might happen to occur. In short, it cannot be deemed arbitrary or un- reasonable for the state, instead of imposing upon the particular employer entire responsibility for losses occurring in his own plant or work, to impose the bur- den upon the industry through a system of occupation taxes limited to the actual losses occurring in the respective classes of occupation. The same question is still more decisively settled by the decision of the United States Supreme Court in the Oklahoma bank deposit guaran- tee case in which a law was upheld which placed a tax upon all state banks to form a deposit insurance fund. The Court in regard to the Oklahoma case said:^ This court sustained an Oklahoma statute which levied upon every bank existing under the laws of the state an assessment of a percentage of the bank's average deposits, for the purpose of creating a guaranty fund to make good the losses of depositors in insolvent banks. There, as here, the collection and dis- tribution of the fund were made a matter of public administration, and the fund was created not by general taxation, but by a special imposition in the nature of an occupation tax upon'all banks existing under the laws of the state. ' Mountain Timber Co. vs. Washington, 37 Sup. , Ct. Rep. 267. - Noble State Bank vs. Haskell, 219 U. S. 104. 127 THE BENEFITS TO EACH The responsibility for sickness is not the sole criterion in fixing a reasonable liability. The benefits to each party which may be expected from a comprehensive plan of distributing the burden by insurance and from the improved health which is expected to follow, must also be taken into consideration. What are those benefits? To the individual there is a direct gain.. The loss of wages from sickness which now falls entirely upon him will be partly borne by others. The cost of medical care which has fallen upon the individual, unless shifted by him to the public or to philanthropy, will be distributed. Moreover, organization of medical service will enable him to have complete care which now only the rich can buy or which the poor may accept as a charity. Lastly, reduced earning power which makes the worker partly or entirely dependent throughout life will be partly compensated without the stigma of charity. Industry will profit at least to the extent that the health of the workers is impi'oved. As a representative of both the National Asso- ciation of Manufacturers and the National Association of Machine- Tool-Builders has said, "It is self evident that . . well employers and well employees add to the strength of an industry.'" Any plan which promises to cut down the labor turnover and labor absences, especially in the more stable part of the employment, will be directly and immediately profitable to the employer. The benefit to the public is clear and unmistakable. The United States Supreme Court, speaking of the interest of the public in the in- surance of accidents said:^ One of the grounds of its concern with the continued life and earning power of the individual is its interest in the prevention of pauperism,, with its con- comitants of vice and crime. And, in our opinion, laws regulating the responsi- bility of employers for the injury or death of employees, arising out of the em- ployment, bear so close a relation to the protection of the lives and safety of those concerned that they properly may be regarded as coming within the category of police regulations. The public of Ohio spends many millions in the care of the sick and the destitute. The public will gain by stabilizing society and preventing the accessions to economic dependence which follow in the train of sick- ness. THE PRINCIPLE, OF THE LIVING WAGE A third approach to the liability of industry and the community may be found in the principle of the minimum wage. This principle is ^ Frank Dresser, United States Bureau of Labor Statistics, Bulletin No. 212, p. 572. ' Sherlock -vs. Ailing, 93 U. S„ 99, quoted in N. Y. C. R. Co, vs. Whjte, 37 Sup. Ct. Rep., 254, 128 quite clearly recognized today and has been upheld in part, at least, by administrative boards and by the courts. The Constitution of Ohio has recognized the minimum wage. It declares ■} Laws may be passed fixing and regulating the hours of labor establishing a minimum wage and providing for the comfort, health, safety and general welfare of all employees and no other provision of the constitution shall impair or limit this power. It is reasonably certain that a living wage will be established at a not distant date and become the minimum below which no normal human being shall be allowed to work, and no employer shall be allowed to hire. What is this minimum living wage? Dr. John A. Ryan, one of the foremost authorities on the subject, defines the living wage as follows :'■' Every man who is willing to work has, therefore, an inborn right to sustenance from the earth on reasonable terms or conditions. This cannot mean that all persons have a right to equal amounts of sustenance or income; for we have seen on a preceding page that men's needs, the primary title to property, are not equal, and that other canons and factors of distribution have to be allowed some weight in determining the division of goods and opportunities. Neverthe- less, there is a certain minimum of goods to which every worker is entitled by reason of his inherent right of access to the earth. He has a right to at least a decent livelihood. That is, he has a right to so much of the requisites of sustenance as will enable him to live in a manner worthy of a human being. The elements of a decent livelihood may be summarily described 'as : food, clothing and housing sufficient in quantity and quality to maintain the worker in norma! health, in elementary comfort and in an environment suitable to the protection of morality and religion; sufficient provision for the future to bring elementary contentment and security against sickness, accident and invalidity; and sufficient opportunities of recreation, social intercourse, education and church-membership to conserve health and strength and to render possible in some degree the exer- cise of the higher faculties. The three important component parts of a minimum living wage are: I. Present living comforts under decent living conditions for the worker and his dependents. II. Provision against loss by sickness and unemployment.. III. Provision for old age. The first of these has been given most attention in current dis- cussion of the minimum living wage. It is the simpler matter to deter- mine and adjust. It is true that until recently the cost of living did generally enter into consideration in fixing wages. The recent high cost ' Constitution of Ohio, Art. II, Sec. 34. ''John A. Ryan, Distributive Justice, 1916, p. 30. 129 of living has, however, drawn attention sharply to the inadequacy of wages to meet current needs. When it comes to the second and third elements, namely, provision for sickness, unemployment and old age, very little consideration has been given. The situation is tersely summed up by Lewis :^ It happens, as though through some inadvertence, that in making a contract of the greatest possible moment, both parties seem to ignore absolutely certain very important elements. The contract is made as though sickness, accidents, invalidity and old age had been permanently banished from the earth. The daily wage is sufficient only for daily necessities ; a man entitled to support for a life- time unwittingly consents to a wage based upon a portion of that lifetime; for the competition in the field of labor is among the strong, the able-bodied, the efficient; the sick, the maimed, the superannuated are necessarily excluded. The question which ought to be asked in this connection is this: how can a living wage include provision for sickness, unemployment and old age so as to give proper assurance that when any of these con- tingencies arise, support will be provided? Some contend that if em- ployees are given a living wage they will, by themselves, take care of such contingencies. This argument implies that if the worker is given an amount over and above enough to provide for present living, he will in some way lay that much aside for the contingencies of life. What shall be added for this purpose? Shall it be the maximum or the mini- mum of possible losses from sickness? If the maximum should be given, then wages would have to be doubled. If the minimum only should be given, then no one would be protected. Without some plan of insurance no one can tell what sum is necessary as a protection against sickness and old age, for no one can tell whether he will be the victim of unusual disabling sickness at an early date or whether he will be the victim of old age dependency either from sickness, misfortune or unusual length of years. If an amount should be arbitrarily fixed, then that part of the living wage intended for the contingencies of life may be saved and invested and if no contingency arises too early, it will develop by constant ad- ditions and interest accumulation into a reasonably adequate fund for support in sickness, unemployment and old age under normal con- ditions. We know, however, that the products of thrift may be ex- pended by a single prolonged illness of the wage-earner or of a member of his family. If he is unlucky, the most thrifty man may approach old age or continued sickness without means of support. No man can carry his own risk of sickness and dependent old age. It is a gamble if he does. Thrift, will not safely provide for sickness and old age, for thrift without insurance is unable to help those who happen to be the early victims of misfortune or of prolonged illness. 'Frank W. Lewis, State Insurance, 1909, p. 7, 9 I30 There is also the man who will not lay aside the part of his wages intended for sickness and old age. He will spend it all as he goes and society will have on its hands the same problem of dependency as at present. It seems to be beyond all question that a living wage must pro- vide for the whole of life and that nothing short of a comprehensive plan of social insurance can make the living wage really a protection against sickness and old age dependency. Without insurance the risk is not measurable and the amount required for each cannot be determined. The gamble of life remains with all of its dread. With universal in- surance the contingencies of sickness and old age are exactly determi- nable and if it is compulsory it is certain that every individual will be protected when the contingencies of life come. The provision of a minimum wage may be required from employers by law. The application of this theory to provision for sickness would require, in common with the principle of liability and benefits, financial assistance from the employer, toward the provision for sickness among his employees and dependents. All three theories point to the injustice of allowing the entire burden to rest upon the workers and to the justice of apportioning the cost among those responsible. CHAPTER IX SICKNESS PREVENTION MEDICAL AND HEALTH SERVICE IN OHIO Medical Practice There were 8,059 registered physicians in Ohio in 1918, according to the American Medical Association directory. This number is equivalent to one physician to 650 people. Ohio, in its ratio of physicans to popu- laton, does not differ materially from the older and more thickly settled states. In comparison with foreign countries, figures compiled before the war show that : Population per one Physician ' England and Wales 1,537 France 1,969 Germany T. 2,124 Russia 7,865 Austria 2,319 The distribution of physicians within the state of Ohio is not uni- form. For example in 1910 there was one physsician to every 384 persons in a city like Columbus f in rural sections there was one phy- sician for 903 people ; while in some sections of the state there was only one physician to 3,000 and even as high as 5,000 people. The contrast between city and country in respect to medical service is striking. In the t^n mining communities visited by Hayhurst he found an even smaller ratio — an average of one physician to 2,016 people, although the needs of a mining community are greater than an ordinary rural community. He also found that quackery, the use of patent medicines, self-doctoring and drug store prescribing had developed to a consider- able degree. While the number of physicians, if properly distributed, is probably ample for Ohio, the medical service is not adequate because of the indi- vidualistic character of practice, or in other words, because of the lack of organization for medical service. In the hearings of the Commission testimony was given again and again by physicians and laymen that adequate medical service is available now only to the well-to-do who "■American Medical Association, Social Insurance Committee, "Statistics Re- garding the Medical Profession," Social Insurance Series, Pamphlet VII, p. 5. 'Ibid., p. 22. (131) 132 are able to pay and to the very poor who accept medical care as charity. The great body of middle class people cannot buy adequate medical service and will not ask for charity. Under the individualistic prac- tice of medicine this condition is inevitable. Medicine tends to become so highly specialized that individual doctors cannot have the knowledge and equipment necessary for the complete diagnosis and treatment of all kinds of cases. Difficult cases must go from specialist to specialist, each acting independently and each charging a fee. The patient is worn out bodily and financially before a final diagnosis is reached. Waste in such an organization of medical service is apparent. In well organized clinics, the charity patient gets such service without charge. Comparing the facilities for specialist services in rural and urban districts, Davis and Warner say:^ We have contrasted the large city with the small town, to the disadvantage of the latter in respect to medical service. The divergence in facilities is seen to be much less, however, through another method of comparison. In a town, most people cannot secure specialist service because there are no specialists.. But in a large city, where specialists exist in plenty, the mass of the population cannot ob- tain thedr services except through charitable medical institutions. The well-to-do pay the specialists high enough fees to enable them to earn a living in part of their working time, and to spend some of the rest of their time in charitable practice among those who are less fortunate financially. For the middle class, the self- supporting wage-earners and small business men, this situation largely means, as we have seen, that specialist service is sought only in case of grave need, for these people do not wish to accept charity. The mass of general practitioners, further- more, who work in the large city without access to the diagnostic facilities of any medical institution, and who have not the means to provide expensive equipment for themselves, cannot give their patients the best of modern medicine, the best that many of them learned in medical school, any more than the "country doctor" can. Thus the contrast between the large city and the small town is much less marked than appears at first glance. Modern thought in the field of medicine has approved the idea of organized or group practice by which the skill and equipment of several physicians, specialists and dentists are pooled for the benefit of both the patient and the physician. Very little organized practice of medicine is found in Ohio outside of the free clinics and hospitals. The night pay clinic of Lakeside Hospital is believed to be the only pay clinic in the state within the reach of workmen. There a charge of 50 cents gives the service of each specialist. There are already six special departments in this clinic. The experiment in medical organization begun in 1918 by the National Social Unit in Cincinnati has been observed with much interest. The plan consists in organizing the physicians within the territory covered by the Social Unit into a cooperative group with central clinical facilities. * Davis and Warner, Dispensaries, 1918, p. 386. 133 There are undoubtedly here the beginnings of a plan which, when fully developed, will solve many of the problems of adequate medical and health service. Undoubtedly physicians will organize for group practice in time, but the movement should be accelerated by public support. It is the province of the public agencies to provide hospitals and it is within hospitals that organized practice can best be developed. The establish- ment of diagnostic clinics would be a great advance over the present System. After proper diagnosis the general practitioner can generally handle the case. Eventually treatment as well as diagnosis should be organized for the purpose of bringing medical skill to bear in an effective way at the right time and place. Industrial Medicine Within the past ten years a new type of medical organization and service has developed which is certain to have a profound effect upon the entire system of medical practice. We refer to industrial medicine or the organization of medical service within industrial plants. The beginnings of this work are found in the emergency accident service which developed after the passage of employers' liability and work- men's compensation acts. Employers found that quick and thorough treatment often prevented infections, long disabilities and even death of employees. Business judgment dictated that medical service which would prevent disability and restore men more quickly was a good investment. More than 40 industrial medical departments have been established in leading plants in Ohio. Such departments are increasing both in numbers and in service provided. The newer developments of these industrial medical departments are in the direction of preventive medicine on a broad scale. From merely emergency accident institutions they are developing into agencies for the prevention of disease as well as of accidents. They are used to keep employees well by enabling them to have their ills diagnosed in the early stages. Some institutions go so far as to provide treatment also but many give only examination and emergency care, referring the case to the family physician or aiding, in securing specialists or hospital treat- ment. The special function of industrial medicine is to diagnose the case with special reference to the work the man is doing. It is possible to prevent many of the ill effects of * industry by keeping men protected who are predisposed to certain disabilities. The establishment of special clinics in industries is just beginning and bids fair to have a rapid development. Nursing Service There are 5,302 registered nurses in Ohio, not taking into account withdrawals for war service. With the graduation of new classes, the number will be considerably increased. Of these, 480 are public health 134 nurses of whom 360 are employed by public bodies. Nursing service has been developed in 69 centers ; most of which are cities. The bureau is anxious that nursing service, especially in rural districts, for prenatal and postnatal care, child welfare work and school inspection, be ex- tended as rapidly as possible. In this connection, the bureau suggests that legislation be passed authorizing city councils and boards of health to employ public health nurses. Within the State Department of Health there was established in 191 1 the Bureau of Public Health Nursing. Through its director, the bureau aims to encourage communities to institute public health nursing service, to secure the desired nurses and to standardize the work of local public health nurses. The bureau also maintains oversight of persons discharged from public tuberculosis sanatoria and of reported cases of inflamation of the eyes of the newborn. The nursing . centers through- out the state have increased so rapidly that the bureau needs an enlarged staff and increased appropriations to maintain its efficiency. Hospitals There are approximately 150 public and private hospitals and sana- toria in Ohio, with 25,000 beds, exclusive of state hospitals and county infirmaries. There are eleven tuberculosis hospitals either state, county, district or municipal, with 1,519 beds. The state has eight insane asylums with over 12,000 beds; one epileptic hospital with 1,600 beds, besides the hospital facilities of the other state benevolent institutions and of the correctional institutions. Altogether, there are over 40,000 hospital beds for all classes in the state. Hospital facilities are distributed very unevenly throughout the state. Thirty counties are without any hospital facilities within their borders. Some of these counties, however, are within reach of hospitals in. centers of population in other counties. At the same time there are other counties which have to rely entirely upon private institutions or- ganized for profit. Still other counties have such a meager number of hospital beds that they can serve only a small number of the people of the county. In addition, there are several hospitals connected with in- dustrial plants which give emergency treatment, especially in cases of industrial accidents. Some parts of the state are amply provided with hospital facilities to meet present demands. Investigations indicate that in cities having fair hospital facilities 7 per cent to 11 per cent of cases of sickness are treated in the hospitals. The Metropolitan Life Insurance Company sickness survey in Boston shoAved that, in a city designated as having especially satisfactory hospital facilities, 25.7 per cent of the persons reported sick and unable to work were being treated in hospitals.^ A * Frankel and Dublin, A Sickness Survey of Boston, Mass., 1916, p. 18. 135 similar survey by the same company in North Carolina showed that only 3.0 per cent of those sick and unable to work were in hospitals, which is probably a fair average for rural communities.^ In Cleveland which has good hospital facilities 42,124 persons were treated in the hospitals of the city during 1917. Some of these cases came from tributary terri- tory around Cleveland, but the number is a fair index of the needs of a city of 750,000 population. Applying the Cleveland figures to the whole state, if hospital facilities were within reach, there would be up- wards of 300,000 hospital cases a year. While reasonably good hospital facilities are available now in some cities, hospital care does not seem to be available to the great mass of the people even in cities well supplied with hospitals. The idea prevails in many public hospitals that they are established for the destitute and they actually refuse to take people who cannot prove their dependency. In such cities the well-to-do buy service at private hospitals and the charity cases go to the public hospital. For the great self-respecting middle classes there are no hospital facilities which they can afford unless they become charity cases. On the other hand there are public hospitals which appear to be run for profit and in which no charity' cases are received. There is, of course, no defense for this practice. A public hospital should attempt to meet the legitimate minimum needs of all the people without pauper- ization on the one hand or excessive charges on the other. It should not ignore the charity patients unless other satisfactory means are pro- vided and it should permit self-respecting persons to use its services at such cost as they are able to pay. Dispensaries In 1916 there were 30 dispensaries in operation in Ohio. Others have been established since then. It may be estimated that nearly 200,000 persons are treated in the dispensaries of Ohio annually. If dispensary facilities were within reach of all people in the state the number of patients would be much more than doubled. The dispensary is defined as "an institution which organizes the professional equipment and special skill of physicians for the diagnosis, treatment and prevention of disease among ambulatory patients."^ It was intended originally as a means of doctoring the very poor who could pay nothing for treatement. It has come to be a means of treatment for thousands who are not in poverty, but who cannot pay the necessary expenses of thorough diagnosis and treatment. The old test for dis- pensary service was that the recipient must be unable to pay any fee. The new test is "not the ability to pay 'a medical fee' but to pay the ^Frankel and Dublin, Public Health Reports, Reprint No. 367, "A Sickness Survey of North Carolina," 1916, p. 6. 'Davis and WcLmer,' Dispensaries, 1918, p. 27, 136 medical fee required for his particular case at the usual rate charged by competent doctors in his community. In other words, cost of service needed, in relation to the financial ability of the patient is the real test."^ Within the dispensaries, therefore, different types of clinics have been developed, some of which are free and some of which charge a small fee sufificient to cover the actual cost of service, but within reach of the wage-earner. There are hundreds of thousands of untreated cases of sickness and disability among our people, due to the lack of organ- ized medical service and the inability to meet the existing costs. The Metropolitan sickness surveys indicated that 25 per cent to 40 per cent of persons reported sick were not receiving medical attention. Among those sick and unable to work the percentage without medical attendance was smaller, from about 45 per cent to 35 per cent, while those sick but able to work were without medical attention in from 50 per cent to 60 per cent of the 'cases. AH the facts point to the conclusion that we need a democratization of medical service. Health Department Turning to the public facilities for protection of health we find a curious anomaly of a completely organized, efScient state department of health and disorganized, inefficient local health administration. The State Department of Health is organized at present with a State Health Council consisiting of five members. The state Health Commissioner, who is appointed by the council and is ex officio a member of that body, is given ample powers to administer the health laws of the state. The State Health Council may also make rules and regulations which have the force and effect of laws. The State Department of Health has at present the following divisions: administration, sanitary engineering, hygienic laboratories, communicable diseases, public health education, tuberculosis, industrial hygiene, child hygiene and plumbing inspection. Apparently nothing further is needed except enlarged appropriations from time to time to meet the expanding needs of these divisions and to establish new divisions as need arises. The local health administration consists of 2,141 health boards and officers, acting for the cities, villages and townships. The cities are authorized to appoint health boards or health officers. The villages and townships have health boards but in lieu of boards, they may appoint health officers with the approval of the State Department of Health. At present only five cities in the state have a full time health officer and no village or township has a full time health officer. Only about a dozen cities can be said to have anything like a reasonably ade- quate health department for the protection of the public health. ^ Davis and Warner, Dispensaries, 1918, p. 64, 137 Owing to traditional indifference, the local health unit has been treated almost as a joke. The State Department of Health published recently the occupation, age and yearly compensation of seventeen local health officers chosen by villages to serve in lieu of boards of health, officers whose appointments were confirmed by the department during one month. This information is given below. Occupation, Age and Annual Compensation of Seventeen Local Health Officers'^ Annual Occupation Age compensation Barber 47 $60 Farmer 37 12 Farmer 60 10 Laborer 33 10 Laborer 45 65 Miller 36 12 Oil worker 44 20 Physician 51 fees Physician 35 No salary Physician 69 25 Physician Age not given 4 Physician 66 50 Physician 53 15 Physician ' 35 No salary Retired 67 25 Teacher 33 10 These appointments are typical of the situation throughout the state. They tell the story of the failure of local health administrations. The system is wrong from every point of view. The health unit is too small to employ trained health officers for full time, and without well-equipped officers protection against epidemics is impossible, to say nothing of the new duties of health promotion. The smallest unit which can be used effectively is the county or district approximately the size of a county. The county is large enough and the health problems important enough to warrant the employment of an all time health officer with sufficient assistants to meet all the requirements of the old and the new duties in matters of public health. The work of public health nurses has already been discussed with approval. (Page 31). Under the local health officer there should be a sufficient number of public health nurses to carry the benefits of better health into the remotest part of the country districts. Under the local health officer, health supervision of schools, outlined in Chapter 11,^ should be organized. Laboratories of hygiene should also be created as a part of the local health work. Such laboratories will enable quick analysis of specimens and make prevention of contagious diseases more ' Ohio Public Health Journal, June, 1918, p. 242. " See p. 33. 138 certain. The establishment of diagnostic cHnics around which medical practice could center is another development which the local health ad- ministration should foster. Community hospitals, when established, should be under the control of the local health officer and should become health centers from which many activities for the welfare of the people should radiate. The way should be left open for the local health units to go as far as they desire in the promotion of public health. The larger cities already have a health organization and these depart- ments should be continued as separate health units. The smaller cities should be grouped with the county or district under one health admin- istration. The whole should, of course, be under the supervision and control of the State Department of Health. FEEBLE-MINDEDNESS Different estimates have been made concerning the extent of feeble- mindedness among the general population. A common method of calcu- lation is to survey the extent of defect among persons confined in the state institutions or children attending public schools and to use these figures as an index of the general situation. During 1916 and 1917, a mental survey was made of all the public schools in Columbus. The total school population was 19,269. From this number 743 children who appeared sub-normal were examined; 164 were found to be feeble-minded; 120 were borderline cases; 459 were not feeble-minded. Dr. H. H. Goddard of the Ohio Bureau of Juvenile Research states that the so-called borderline cases cannot be classed as definitely feeble-minded, because the subject may be too young to clearly exhibit his deficiency which with advancing years may become apparent. Combining the two groups, there are 284 children at least below normal or 1.4 per cent of the school population. Applying this percentage to the state, there are 11,362 feeble-minded children. Dr Goddard believes that at least 2 per cent of 'the school children throughout the country are feeble-minded; The total enrollment of the elementary schools in 1910 as given by the report of the Commission of Education was 18,339,828. One per cent of this number is 183,339 or approximately 40 per cent of the estimated number of feeble-minded in the United States in 1910. The following figures show the results of examinations made by ' the Bureau of Juvenile Research in Ohio children's homes. There was a total population of 1,266; of these 124 were classified as feeble-minded; 67 as borderline cases; a total of 191 or 15.0 per cent of all children in the homes, classed as below normal. Not all the children in the larger homes were tested, only those suspected of being retarded. Among the inmates of penal and semi-penal institutions, it is reason- able to expect a high rate of defect. Dr. Thomas H. Haines, formerly clinical director of the Bureau of Juvenile Research, examined 671 boys and 329 girls by two different tests finding 57 per cent feeble-minded by 139 the Binet-Simon and 29 per cent feeble-minded by the Yerkes-Bridges tests. Similar studies made by the Bureau of Juvenile Research among 164 children in the Cleveland farms showed 50 per cent below normal. Miss Bowler, formerly field worker for the bureau, after making a study of 75 girls who had been in the industrial home at Delaware, Ohio, for about two years, concluded that: "By an extremely conservative count, one-fifth of all girls admitted are definitely feeble-minded." An enumeration of defectives throughout the United States was first attempted by the United States Bureau of the Census in 1880. Figures gathered by the census showed that in Ohio in 1880, out of a total popu- lation of 3,198,062 there were 6,462 or 0.2 per cent idiots; and in 1890 for a population of 3,672,316 that there were 8,035 feeble-minded persons in Ohio, or 0.2 per cent of the total. The discrepancy in the percentages of the population returned as feeble-minded by mental tests and by census enumeration is due to the different methods employed. The mental tests establish as feeble-minded suspected cases. The census enumeration includes only those who are reported as such by their families. The results of the mental tests are more accurate although, of course, they are less extensive. The Ohio Board of Administration published in March, 191 5, an article by Dr. E. J. Emerick, superintendent of the Ohio Institution for the Feeble-minded, on "The Problem of the Feeble-minded." In this he states that: The number of feeble-minded is estimated at from 10,000 to 15,000. Yet Ohio's Institution for the Feeble-minded can take care of only 1,939 of these (.1915) less than 20 per cent. Some of the rest are in infirmaries ; many are in the re- formatories and penitentiary from time to time; still others go to swell the num- ber of juvenile delinquents at our industrial schools; while the mass of Ohio's feeble-minded are at large in the community. These feeble-minded individuals outside of institutions, incapable of getting on well without permanent care and guidance, yet left free to perpetuate the defective stock, present a problem, the seriousness of which we are just beginning to appreciate. And there are at least 8,000 such individuals at large in Ohio today. In the special United States census of the feeble-minded in 1910, it is estimated that in the United States as a whole not more than 10 per cent of the feeble-minded are in special institutions.* According to this census there were 20,731 feeble-minded in special institutions in conti- nental United States in 1910. An allowance of one feeble-minded person to every 200 in the general population, which is the ratio accepted above, gives only 4.5 per cent of the feeble-minded cared for in special insti- tutions. The results of the mental tests given to various groups in the army is shown in the following table. ' U. S. Bureau of the Census, Insane and Feeble-minded, Feeble-minded in In- stitutions, p. 184. 140 Number of Persons Examined and Per Cent Earning Each Rating ' Number of per- sons ex- amined Per cent distribution Various groups (Whites) Inferior intelligence Average intelligence Superior intelligence • Very in- ferior In- ferior Low age aver- Aver- age High aver- age Su- perior Very su- perior Officers Commissioned oiiticers .... 8,819 9,240 3,393 4,023 81,114 10,803 0.2 1.0 4.0 7.8 21.5 29.1 2.2 6.2 14.2 20.3 28.8 14.7 13.8 19.5 27.3 31.3 20.5 4.4 34.6 36.4 32.5 26.0 ■12.4 1.9 48.4 Officers' train- ing corps candidates . Sergeants Corporals Privates Literate Illiterate 0.2 7.8 0.1 1.0 1.3 10.2 41.2 36.8 20.9 13.7 6.4 0.5 'L. M. Terman, "The Use of Intelligence Tests in the Army," The Psy- chological Bulletin, June 1918, p. 183. I '1 _« :l!." ; LlSlJtl The men who were classified as being of low average intelligence make good privates and are capable of satisfactory work of a routine nature.^ Those of inferior intelligence rarely go above the rank of private, they are short on initiative and require more supervision; of those with very inferior intelligence, having the average intelligence of a normal nine and a half year old child or below, slightly over i per cent were judged fit for regular service and the others were recommended for the development battalion, the special service organization, or dis- charge. The classification of the entire group examined according to mental age implied in the above classification is given below : Number of Persons Examined and Per Cent Distribution by Mental Age ' Various groups Number of persons ex- amined Per cent distribution by mental age (Whites) 12.9 or below 13.0 to 16.4 16.5 to 19.2 Officers 25,475 91,917 2.5 37.4 28.8 45.7 68.7 16.8 Privates Total 117,392 29.8 42.1 28.1 'Based on L. M. Terman, "The Use of Intelligence Tests in the Armv The Psychological Bulletin, June 1918, p. 183. 'The Official United States Bulletin, Dec. 11, 1918, p. 3 141 In February 1918, the Bureau of Juvenile Research published a report entitled "The Feeble-Minded in a Rural County of Ohio." The county was in the hilly portion of the southeastern section of the state, bordering on the Ohio River. On February 15, 1916, there were 253 persons in the various state institutions from the county studied. O.f this number under state control, 16 per cent were known to.be feeble-minded but less than 8 per cent were inmates of the institution for the feeble- minded. Tt was estimated that 47 per cent of the infirmary population was dependent because of feeble-mindedness. Only 35 per cent were dependent because of infirmity due to old age or illness. There was about five times as much feeble-mindedness among the dependent children in the Children's Home as among the public school children of the county. There were two district schools in which more than 40 per cent of the children were feeble-minded. The percentage of feeble-minded at large in the rural districts was double the percentage at large in urban districts Thirteen and a half per cent of the total feeble-minded population oi the county belonged to one family strain. Approximately i per cent of" the total population was found to be feeble-minded. One of the most important steps taken towards the solution of the problem of dealing with the feeble-minded reasonably, was the estab- lishment in June 1914 of the Bureau of Juvenile Research as a branch of the Ohio Board of Administration. Its establishment means that the Board of Administration may "assign any child committed to its guard- ianship to the Bureau of Juvenile Research for the purpose of niental, physical and other examinations, inquiry or treatment for such period of time as such board may deem necessary,'" in order to afford the board the opportunity of disposing of the problem of child welfare more wisely. Temporary treatment is provided until the board commits the child to an institute or releases it. The bureau is equipped with laboratory and detention facilities and has jurisdiction over any minor "from any public institution, other than a state institution, or from any private charitable institution, or person having legal custody ^thereof." Among other func- tions, the bureau is (i) to encourage the establishment of local clinics in the larger cities of the state, where proper studies can be made of delinquent and dependent children; (2) to exercise the power of super- vision, visitation and control, as far as authorized by law, over all mental defectives not in institutions; (3) to conduct continuous research and investigation for improving the methods employed in dealing with mental defectives ; and (4) to establish close working relations with the public schools in order to encourage special classes for the defective as well as, in planning for them.' The question of the degree of accuracy with which general intelli- gence may be measured has heretofore been questioned. Dr. Goddard, ^ Ohio General Code, Section 1841-1 to 7. 142 in a discussion relating to the application of such tests, calls attention to the fact that they have received the approval of the United States Government after long and careful investigation. The results of the tests in the army have been verified by the experiences of the command- ing officers. It is no longer possible for anyone who knows the facts to deny their value.^ In commenting upon the application of these tests, Dr. Goddard remarks : The tests show an unexpected high degree of low grade intelligence. This means that we can no longer be surprised when we find two per cent and perhaps three and four per cent of the children in our public schools are of such low in- telligence that they cannot do the work usually prescribed for them. The logical conclusion from this is that we must make the discovery and training of back- ward and defective children a permanent part of our public school work. The whole problem of dependents and delinquents is the problem of edu- cation — not education as it is usually understood, that is to say, book knowledge, but rather an industrial education that is within the limits of their capacity and which will fit them for some place in which they can earn a livelihood. TUBERCULOSIS Tuberculosis, the Ohio Board of Health estimated in 1914, was the cause of one out of every ten deaths in Ohio. One-third of all deaths between the ages of 15 and 50 in Ohio are due to tuberculosis. In com- menting upon the Prussian experience as stated by Kirchner, Dr. Low- man writes :^ It appears that the percentage of deaths from tuberculosis in the last five years (1907) has increased from 1 per cent to 8 per cent for those under 25 years of age, although its total mortality has diminished 20 per cent. The actual number of active cases of tuberculosis is a matter of conjecture notwithstanding that it is a reportable disease. The records of the State Department of Health show that of 933 persons known to be infected only 36 cases or 3.8 per cent were reported by physicians. Of 7.453 deaths in 1917 from this cause, only 6,454 were reported by physicians to the State Department of Health. Of the basis of 7,000 deaths annually, and assuming that there are five cases of tuberculosis for each reported death, it is estimated that there are 35,000 cases in Ohio, i. e. that 0.7 per cent of the estimated population of Ohio have tuberculosis.^ This method of estimating the case rate originated with Newsholme, the leading British authority on public health matters. 'Summary of remarks made by Dr. H. H. Goddard, Director of the Ohio Bureau of Juvenile Research at Mental Hygiene Section of the Ohio Charity Con- ference, Dec. 18, 1918. "John H. Lowman, "Schools and Tuberculosis," National Association for the. Study and Prevention of Tuberculosis, Transactions, 1907, p, 108. M3 Medical examinations of wage-earners indicate a somewhat higher incidence in this group. For example, the United States Public Health Service examined 19,932 workers in Cincinnati who were employed in 154 factories and workshops representing 38 distinct industries. The examinations showed that 220 or i.i per cent were tuberculous.'' Exami- nations of 32,289 employees of the Sears-Roebuck Co. disclosed that 0.87 per cent or nearly i per cent were tuberculous. Examinations of 20,000 employees of the International Harvester Co. showed substantially the same results. Tuberculosis, according to the analysis of causes of rejections in the first draft of 10,000 cases made by the Provost Marshal, was re- sponsible for 5.37 per cent of the rejections.- If this ratio holds true among all those rejected by draft boards, then 39,242 men were rejected for this cause, or 1.6 per, cent of all those examined by draft boards. This ratio is probably higher than that for the general population as a whole because the group examined includes only men in an age group in which the incidence of tuberculosis is high. It is the concensus of opinion that there are certain factors predis- posing to tuberculosis. This was pointed out by the survey of the United States Public Health Service in Cincinnati. These investigators after an intensive study of the 220 cases of tuberculosis among industrial workers stated the following conclusions;^ The consideration of the whole subject of tuberculosis in the City of Cin- cinnati seems to warrant the following general conclusions : (1) A goodly percentage (estimated at 19.3 per cent) in our series is due to occupation hazard and bad working conditions but in the majority of instances these hazards and bad working conditions are not necessarily inherent in the occupation, most of the deleterious factory influences found being those -which existing legislation is adequate to remove. (2) Although family infection and hereditary predisposition were the pre- disposing factors most in evidence, the elements of poverty, and poor housing undoubtedly overlap these factors and in many instances intensified their influence. (3) Although the connection between alcoholism and the contraction of the disease was apparent in only 7.2 per cent of the cases, there was abundant evidence to show that once the disease had started, its course was often accelerated by this factor. • (4) In a large proportion of cases (23.2 per cent) it was impossible to assign chief place to any one predisposing cause. 'Robinson and Wilson, "Tuberculosis among Industrial Workers," Public Health Bulletin No. 73, p. 69. "^ Provost Marshal General, Report to the Secretary of War, 1918, pp. 44, 47. 'Robinson and Wilson, "Tuberculosis among Industrial Workers," Public Health Bulletin No. 73, p. 62. 144 A special study of housing conditions among tuberculosis persons led investigators for the United States Public Health Service to con- clude that :^ (1) The distribution of tuberculosis bears a direct relation to that ai tene- ments, being at the most conservative estimate twice as great among tenement dwellers as among those living in separate houses. (2) The lodging houses are with few exceptions insanitary. They are ■breeders and disseminators of tuberculosis. Prcubably one-sixth of all Cincinnati's tuberculosis cases originate in rooming and lodging house . . . (4) Thirty-two per cent of the homes visited had poor ventilation. (5) Sixty-one per cent of the tuberculous persons were sleeping. in the same room and often in the same bed with non-tuberculous members of the family. (6) Poor toilet and bathing facilities, poor ventilation, and over-crowding are largely due to bad economic conditions, the average family income being insufficient either to procure more commodious quarters, or properly to heat the ones occupied. Certain types of work, Hoffman has shown predispose the worker to tuberculosis.^ Typical employments with metallic dust exposure are file cutters, copper- smiths, engravers, printers, lithographers, nail workers, machinists, gunsmiths, etc. Persons in all of these employments or industries are subject, as a general rule, to an exceptionally high mortality rate from all causes, and a high specific death rate from pulmonary tuberculosis. The proportionate mortality from pulmonary tuberculosis in occupations with exposure to metallic dust is 31.7 per cent for all ages, which compares with 21 per cent as shown by the census mortality returns. The differences are quite marked and a maximum proportion is reached at ages 25 to 34 when out of 2,504 deaths from all causes among men with exposure to metallic dust, 1,243 or 49.6 per cent were deaths from pulmonary tuberculosis. The Ohio Society for the Prevention and Study of Tuberculosis has been foremost in the campaign against tuberculosis in the state. The society was organized in igoi but the facilities for their work were very limited. In 1904 the Legislature provided funds for the establish- ment of an institution to care for incipient cases. In 1908 provision was made for county hospitals, a law which was later repealed. In 1910 a law was passed permitting boards of education in cities to establish open-air schools. In 1913 an appropriation of $20,000 was made to the Ohio State Board of Health for the purpose of fighting tuberculosis. The activities of the two organizations have been closely related and to a great extent supplement each other. There are at the present time 76 committees or organizations working with the tuberculosis association, aside from the community health officers. ^Robinson and Wilson, "Tuberculosis among Industrial Workers," Public Health Bulletin No. ys, p. 84. ^Frederick L. Hoffman, "Mortality from Respiratory Diseases in Dusty Trades," United States Bureau of Labor Statistics, Bulletin No. 231, pp. 51, 52. 145 As a result of these years of effort there are today in Ohio fourteen pubHc and semi-public institutions which care for tuberculous patients. The names of these institutions and the accomodations of each are given in the accompanying table. Number of Hospital Beds in Public and Semi-Public Institutions in Ohio Available for the Treatment of Tuberculous Persons, 1918 Institution Number of beds Per cent distribution State Ohio State Sanatorium 170 32 40 50 40 110 10 7 District Chillicothe 2.0 Dayton 2.5 3.2 SorinErfield. 2.5 6.9 Total 272 20 110 147 17.1 County- Butler 1.2 Franklin 6.9 Lucas 9.2 Total 277 430 370 17.3 Municipal Cincinnati 26.9 Cleveland 23.3 Total 800 30 25 20 50.2 Semi-public 1.9 1.6 St Anthony's HosDital 1.2 Total 75 4.7 : 1,594 100.0 ^ There are 212 tuberculosis beds in two state insane hospitals and the Soldiers' Home at Dayton. Two more districts have been organized recently and when these sanatoria are equipped, it will bring the total accomodations up to 1,700 beds. This, however, falls far short of the estimated minimum of 5,000 beds required for Ohio.^ The numbers admitted to ten institutions in Ohio, numbers dis- charged and patients' condition on discharge are given in the following table. 'Ohio State Department of Health, "Ohio's Tuberculosis Hospital Equip- ment," Ohio Public Health Journal, Aug. 1918. 10 146 Number and Condition- of Patients Admitted to and Discharged from Ten Tuber- culosis Sanatoria, 1915, 1916 and 1917. Condition of patient 1915 1916 1917 Number Per cent Number Per cent (Number Per cent Admissions Early 78 165 167 16 18.3 38.7 39.2 3.8 282 557 534 112 19.0 37.5 36.0 7.5 220 395 223 383 18 Moderately ad- vanced 32 3 Advanced 18.3 Far advanced 31.4 Total 426 109 170 138 132 100.0 19.8 31.0 25.1 24.1 1,485 177 533 408 357 100.0 12.0 36.1 27.7 24.2 1,221 81 291 378 458 100 Discharges Arrested 6 7 Improved 24 1 Unimproved Died 31.3 37 9 Total 549 100.0 1,475 100.0 1,208 100 This table brings out clearly the significant numerical and propor- tional increase of far advanced cases admitted. In 1915 but 3.8 per cent of those admitted were classed as far advanced; in 1917 this per- centage had increased to 31.4 per cent. The parallel increase in the numbers and percentages of patients who are discharged as unimproved and who die, indicates that the increased admissions of far advanced cases is a very real increase and not one due merely to possible changes in classification. It is quite generally agreed that an adequate provision of hospital beds to care for advanced cases of tuberculosis is a consideration of importance in controlling the disease. The provision of sufficient care for incipient cases is really the determining factor from the broader standpoint of public health and disease prevention. Early diagnosis and careful supervision through clinics and public health nurses may afford the opportunity for a valuable educational program largely preventive in character; but the curative work must be carried on through well equipped sanatoria and hospitals. Unless some such provision is made- for careful attention during the early stages, many persons who could be reinstated and at least made capable of self-support will become depend- ents of the state. Adequate provision should be made for the constant supervision of those discharged with an active infection in order to avoid the spread of further infection. At present this work falls largely uppii the public health nurses. 147 VENEREAL DISEASES' The State of Ohio had approximately 5,285,000 persons July i, 1918. On a conservative basis 10 per cent or 528,000 of this population are infected with syphilis. The New York City Department of Health estimates that eight out of every ten young men have had gonorrhoea at some time in their lives. A reduction of this estimate to five out of every ten, indicates that in Ohio about 1,250,000 of the male population and at least 500,000 of the females have had a gonorrheal infection at some time. The incomplete reports to the State Department of Health show syphilis as the cause of death in 454 cases in 1917, and opthalmia neona- torium returned as a communicable disease, in 1,641 cas^s. During the same year syphilis was reported in 814 cases and gonorrhoea in 1,454, which is far below the actual number. A conservative estimate attributes 20 per cent of nervous disorders to syphiHs. On this basis, approximately 1,600 of the 7,999 deaths, due to diseases of the nervous system in 1916, were due to syphilis; and 20 per cent of all the occu- pants of insane hospitals in the State of Ohio are incapacitated by the same disease. This gives an idea of the enormous expense entailed. Moreover, of the 4,574 stillbirths reported in 1916 syphilis was the cause of approximately 50 per cent. The same is true of 50 per cent of all miscarriages. The Public Health Council on May 2nd, 1918, adopted regulations for the prevention of venereal diseases which are effective on and after July 1st, 1918. The State Department of Health plans to go before the Legislature with a request that in addition to these regulations two laws be passed to assist it in its work. The first reads as follows : Druggists Forbidden to Prescribe for Venereal Diseases . . . No druggist or other person not a physician licensed under the laws of the state shall prescribe or recommend to any person any drugs, medicines, or other substances to be used for the cure or alleviation of gonorrhoea, syphilis, or chancroid, or shall compound any drugs or medicines for said purpose from any written formula or order not written for the person for whom the drugs or medicines are compounded and not signed by a physician licensed under the laws of the state. The second reads as follows : Advertisements relating to Certain Diseases Prohibited . . . Whoever pub- lishes, delivers or distributes or causes to be published, delivered or distributed in any manner whatsoever an advertisement concerning a venereal disease, lost manhood, lost vitality, impotency, sexual weakness, seminal emissions, varicocele, self-abuse, or excessive sexual indulgence and calling attention to a medicine, article, or preparation that may be used therefor or to a person or persons from whom or 'This statement on venereal diseases was presented to the Commission by Dr. H. N. Cole of Cleveland, director in charge of the venereal disease campaign in Ohio for the State Department of Health and the United States Public Health Service. 148 an office or place at which information, treatment, or advice relating to such disease, infirmity, habit, or condition may te obtained, is guilty of a misdemeanor, and upon conviction thereof shall be punished by imprisonment for not more than six months, or by a fine of not less than $50 nor more than $500, or by both such fine and imprisonment. This section, however, shall not apply to didactic or scientific treatises which do not advertise or call attention to any person or per- sons from whom or any office or place at which information, treatment, or advice may Ibe obtained, nor shall it apply to advertisements or notices issued by an in- corporated hospital, or a licensed dispensary, or by a municipal board or depart- ment of health, or by the Department of Health of the State of Ohio. These provisions, as presented, are self-explanatory and require no further comment. In addition there is outlined a campaign against venereal disease that the Bureau of Venereal Disease thinks would be suitable. Under the Chamberlain-Kahn' act, the State of Ohio was given $51,832.16 by the United States Public Health Service under the fol- lowing proviso: Regulations Promulgated by the Secretary of the Treasury, under which State Boards or State Departments of Health receive the Allotment of Funds provided in Section 6, Chapter XV, of the Act approved July 9, entitled "An Act making Appro- priations for the Support of the Army for the Fiscal Year ending June 30, 1919." ' The act provides that $1,000,000 shall be distributed to the states for the use _ of their respective boards or departments of health in the prevention, control, and treatment of venereal diseases, this sum to be allotted to each state, in accordance with rules and regulations prescribed by the Secretary of the Treasury, in the proportion which its population bears to the population of the continental United States, exclusive of Alaska and the Canal Zone, according to the last preceding United States census. State boards or departments of health receiving their respective allotments shall agree to the following co-operative measures under which their appropriation shall be expended : 1. Put into operation through a legislative enactment or a state board of health regulation having the effect of law, regulations in conformity with the suggestions approved by the Surgeons General of the Army, Navy, and United States Public Health Service, for the prevention of venereal diseases. The min- imum requirements of these rules are : (a) Venereal diseases must be reported to the local health authorities in accordance with State regulations approved by the United States Public Health Service. (b) Penalty to be imposed upon physicians or others required to report venereal infections for failure to do so. (c) Cases to be investigated, so far as practicable, to discover and con- trol the sources of infection. (d) The spread of venereal diseases should be declared unlawful. (e) Provision to be made 'for control of infected persons that do not co-operate in protecting others from infection. •United States Public Health Service, Public Health Report, September 13, 1918, pp. 1537-40. 149 (f) The travel of vener-eally infected persons within the State to be controlled by State boards of health bf definite regulations that will conform in general to the interstate regulations to be established. (g) Patients to be given a printed circular of instructions informing them of the necessity of measures to prevent the spread of infection and of the importance of continuing treatment. 2. An officer of the Public Health Service shall be assigned to each State receiving allotments for the general purpose of co-operating with the State health officer -in supervising the venereal-control work in the State. This officer to be selected by the State health authorities and to be approved and recommended for appointment by the Surgeon General oi the Public Health Service. The salary of this officer will be paid by the State out of the funds made available from the allotment, except a nominal sum of $10 per month, which will be paid by the United States Public Health Service. In those States where a bureau of venereal diseases has already been established, with a full-time medical officer in charge, the present incumbent may ibe recommended for appointment by the State health officer, and, with the approval of the Surgeon General, United States Public Health Service, he will be appointed as an officer of the Public Health Service. The general plan of work for the State bureau of venereal diseases will be: (a) Securing reports of venereal infections from physicians and others required to report, in accordance with State laws. (b) Suppressive measures, including the isolation and treatment in de- tention hospitals of infected persons who are unable or unwilling to take measures to prevent themselves becoming a menace to others, the establish- ment of free clinics for the treatment of venereal diseases," and the elimina- tion of conditions favorable to the spread of venereal infections. (c) Extension of facilities for early diagnosis and treatment through laboratory facilities for exact diagnosis and scientific determination of con- dition before release as non-infectious, in accordance with the standardized procedure that will be prescribed by the United States Public Health Service. (d) Educational measures to include informing the general piiblic, as well as infected individuals, in regard to the nature and manner of spread of venereal diseases and the measures that should be taken to combat them. (e) Co-operation with local civil authorities in their efforts to sup- press public and clandestine prostitution. The clinics referred to under (b) will form centers from which the other measures may be conducted by dis- covering the presence of infections, the securing of data for enforcing the regulations for reporting these diseases, and the institution of educational measures appropriate to particular communities. The immediate reduction in venereal-disease foci resulting from clinic treatment will result in a marked decrease in the prevalence of such diseases in both the military and civil population. (f) Accurate detailed records must be kept of all the activities of the venereal-disease work. These will include careful records of each case treated, amount of arsphenamine used, final results, and disposition made of patients. Copies of these records must be forwarded to the Surgeon Gen- eral, United States Public Health Service, as a report at such intervals as they may be requested, and in accordance with instructions regarding the form of report. 3. Local funds that may be available, or that may become available from legislative appropriations or any other source for venereal-disease control, shall be used by the State or city health authorities having jurisdiction for the exten- sion of the work, and such local funds must not be conserved through the expendi- ISO ture of the funds that are allotted by the Congress through the United States Public Health Service. 4. In extension of the educational measures the State's health authorities and its bureau of venereal diseases shall exert their efforts and influence for the organization of a State venereal-disease committee that will be unofficial in char- acter, but a valuable co-operative agency for furthering the comprehensive plan for Nation-wide venereal-disease control. 5. The State health authorities shall take such measures as may be found practicable and decided upon in conference between the Public Health Service and the State board of health representatives for the purpose of securing such additional legislation as may be required for the development of conttol of the spread of venereal infections. Action shall be taken to limit or suppress the activities of advertising "specialists" and quacks by prosecuting them under State laws, or such other measures as may be applicable and effective. 6. In expending the sum allotted a State, the rules and regulations to be promulgated by the interdepartmental social hygiene board for the expenditure of the $1,000,000 civilian quarantine and isolation fund under control of the Sec- retary of War and Secretary of the Navy shall be given consideration by Public Health Service and State board of health representatives, so that the military necessities of each particular State may receive the consideration due its relative importance, and so that funds from the two sources may be correlated. 7. The State allotment shall be expended along general standard lines for all States and in accordance with an accounting system, to be forwarded by the interdepartmental social hygiene board, approximately as follows : (a) For treatment of infected persons in hospitals, clinics, and other institutions, including arsphenamine and other drugs, 50 per cent of the allot- ment. (b) In carrying out educational measures, 20 per cent. (c) In carrying out repressive measures, 20 per cent. (d) In general administration and other activities of venereal disease control work, 10 per cent. (This distribution is provisional and subject to modification after conference and agreement between each State and the United States Public Health Service to best meet the needs of the particular State.) 8. In carrying out the general Government program the administrative organization of the United States Public Health Service will be available at all times to State organizations in co-operative work, and assistance will be given to States whenever possible through the detail of employees, the securing of arsphenamine, providing literature for the educational measures and in such other ' ways as may be found practicable as the work develops. Washington, D. C, Sept. 4, 1918. W. G. McAdoo, Secretary of the Treasury. This grant is available up to July i, 1919, after this date it will be necessary, if further funds are desired, that the Legislature grant one- half of the sum desired and the federal government will provide the other half. The program of the Bureau of Venereal Disease has consisted in carrying _out the regulations of the State Department of Health and in instituting free Wassermann tests and free examination of the smears for gonorrhoea. In addition, the Bureau of Venereal Disease has estab- 151 lished seven venereal disease clinics in charge of United States Public Health Service officers, clinics which are available for the diagnosis and treatment of venereal diseases. The State Department of Health assists in financing the United States Public Health Service extra-cantonment venereal disease clinic at Chillicothe. It is now starting another clinic in Lorain and one in Ashtabula. Several other clinics are under discus- sion. These clinics have salaried social service nurses to follow up the cases and to keep in touch with them. In the matter of hospital beds, although there has been a deplorable lack so far, arrangements have already been made for the care of several hundreds cases in different parts of the state. Several so-called "red light districts" have already been closed, and at present several more are under surveillance. As a part of the educational program, placards have been sent over the entire state explaining the consequences of venereal infection; a series of pamphlets, "Some Things a Young Man Should Know About Sex and Sex Diseases," "Instructing Your Child in the Facts of Sex," and "How Any Boy Can Develop His Health and Strength," have been distributed; hundreds of letters of inquiry have been answered; and public lectures have been given to Y. M. C. A.'s, churches, clubs, educa- tional societies, industrial plants, etc. This literature has placed au- thentic information before thousands. The bureau is now giving to all Class I men in the state an illustrated moving picture lesson on venereal diseases, under the auspices of the United States Public Health Service. The United States Railroad Administration has requested that placards on venereal disease be placed in the toilets of all Pullmans and coaches in this district so that within the next month or two practically all the cars in the district comprising Michigan, Illinois, Indiana, Ken- tucky and Ohio will have these placards of the Bureau of Venereal Diseases of the State of Ohio. In the month of January a lecture is being planned to reach all high school boys in cities above 8,000 in the state and the advisability of securing the cooperation of several women in order to reach children and girls is being discussed. Plans for the next year must be even larger and more comprehensive. They may be outlined somewhat as follows : Careful reports on all cases of venereal disease must be obtained; sources of infection must be closely watched and quarantined ; all cases of venereal disease must be kept under closer surveillance if the rate in the state is to be lowered, although Ohio's present rate is rather mislead- ing because of failure to report cases. All citizens and communities should take the greatest interest in this work and cooperate with the Bureau of Venereal Diseases in establishing clinics and securing hospital beds, because it is only through adequate hospital treatment that we can hope to get permanent results. This is also true of many cases in the first stages of syphilis. 152 Moreover, the bureau is firmly convinced that the State of Ohio must adopt a plan similar to that of Virginia, Michigan, Kansas, Con- necticut and several other places if we wish to protect the small com- munities. Reference is made to the establishment of a large central hospital farm where the prostitutes and those venereally dangerous to others may be placed for a length of time, where they may receive care- ful treatment both physical and mental, and, where, if necessary, they may even be quarantined. This is an urgent need in the State of Ohio. At present the bureau is hesitating to close about seventy houses of prostitution because there is no provision made to care for the women after their arrest. Experience in other communities has shown that about 90 per cent of the women have gonorrhoea, that from 50 to 60 per cent oi them have syphilis in contagious stages and that there are practically none without some venereal disease. It is worse than useless to arrest them until immediate and adequate treatment can be provided. There are several such black spots in the state at present and the bureau asks the cooperation of your Commission in securing legislation which will help it establish such a central hospital farm. PART II: HEALTH INSURANCE (153) CHAPTER X HEALTH INSURANCE The foregoing chapters have brought out clearly the hazard of sick- ness. No further facts or arguments are needed to show that the bur- den of sickness falls with crushing force upon some people every year. Tables showing the distribution of sickness indicate that about 20 per cent will be disabled more than one week. Of those who are disabled, 19.8 per cent will be disabled for four weeks or over but less than eight weeks ; 6.4 per cent will, be disabled for eight weeks or over but less than 12 weeks; 3.0 per cent more than six months; 1.2 per cent more than a year. Those who are sick more than 30 days are often quite seriously handicapped; those who are sick for three months or more are quite likely to be dependent upon some one or upon the public. Data as to the cost of medical care bring out a corresponding inequality in medical costs. In a group of 508 families in Toledo, Lorain and- Cleveland, which averaged $41.79 for medical expenses, three had no expenditure, while six had over $300 each. A group of 211 families in Columbus had an average expense of $42.41 ; 41 had less than $10 average expense, while two had over $200 each. THE INSURANCE PRINCIPLE But while sickness is a hazard for the individual, it occurs with measurable regularity in a group. This is the hazard which insurance is intended to meet. It is the function of insurance to distribute the losses among all persons who are subjected to a specified risk which may be ascertained for the group. Sickness is a risk for every person and is a serious hazard for the wage-earner whose only capital is his ability to work. The risk is not that a person may be sick, but that he may suffer disabling sickness prolonged to the point where he becomes economically dependent. - Confronted with the risks of property loss, men have quite generally resorted to insurance. When men invested their all in a maritime ven- ture they might become beggars in a day through an ocean storm. By pooling their losses through marine insurance they eliminated the risk of disaster to any one owner. Men next learned that the hazard of fires could be measured and the losses distributed by insurance. Few people today fail to insure their property against fire. For generations we have publicly insured the owners of sheep by (155) 156 collecting a tax upon dogs to create a fund from which damage to sheep by dogs would be paid to the owners who suffered the damage. The state of Indiana in 1909 went further and created a fund out of the dog tax to pay for treatment of persons bitten by mad dogs. The province of Alberta, Canada, gives another example of distributing risks by the creation of public hail insurance. There a tax is levied upon every acre of agricultural land to create a fund from which to reimburse owners of crops for any losses caused by hail. North Dakota and South Dakota adopted constitutional amendments for hail insurance at the last election. A number of states insure bank deposits by providing a fund from which losses are paid. The application of insurance to human losses has developed much more slowly than its application to material losses. This is due partly to the acceptance of sickness, accident and death as visitations of fate which cannot be measured and insured. Life insurance was the only branch which, down to 1910, had developed extensively. This is due to the accuracy of the early mortality tables and to the active work of insurance companies, their solicitors and fraternal orders. Until the passage of workmen's compensation acts, beginning in 191 1, there was relatively little accident insurance for workers. Since then it has be- come almost universal as a result of state compulsion. The slowness of the development by private companies of personal accident and health insurance may be traced in part to the inaccuracies of the early rate tables. Today only a slight fraction of the loss from sickness is insured and distributed. The burden of sickness rests where it falls ■ — upon the disabled man and his dependents. CAN EXISTING AGENCIES MEET THE NEED? It has already been estimated that approximately 35 per cent of the employees in Ohio have some health insurance in fraternals, trade unions, establishment funds or in commercial companies. The insurance is, however, for only a fraction of the loss caused by sickness. Prac- tically no medical benefits are given; there is no protection for the permanent loss of working power and the cash payments amount in most cases to $5.00 to $7.00 a week for a period varying from 13 to 26 weeks. It is proper to deduce from these figures that not over 10 to 15 per cent of the risk upon 35 per cent of the workers is covered by sick- ness insurance. It would seem to be possible to expand the business of existing carriers to provide medical care and to cover a greater part of the wage loss by enlarging the weekly payments and by extending the period of benefit payment. An efficient and economically administered medical service presupposes, however, large numbers in relatively small areas. The geographically scattered'membership of present day health msurance 157 carriers does not afford this opportunity. It is very difficult, therefore, from the nature and the requirements of adequate medical service for existing carriers to provide it. It is also extremely doubtful whether existing carriers can materially increase the cash benefits without coupling therewith an adequate medical service to supervise the claims and re- store earning capacity as rapidly as possible. But these suggestions are academic since the wage-earners are paying for as liberal benefits as they feel they can afford. It may be argued by some that the 4>resent carriers could furnish the cash benefits and that the medical benefits might be organized by the state. The weakness of this proposition lies in the fact that experience goes to show that the cash and medical benefits must be administered by the same organization if the expenditure upon cash benefits is to produce, as a measure of economy, the desired social result of prevention of disease and quick restoration of disabled men. If existing agencies are to meet the need, it is essential that the mem- bership be greatly extended so that all in need of insurance protection may be covered. But experience the world over shows that no scheme of voluntary insurance will be anything like universal and that those who most need insurance often fail to insure upon their own initiative. There is considerable corroborative evidence of the limitations of private health insurance. The Prudential Insurance Company has tried it and has abandoned the attempt. Of its experience in this field, its former president, John F. Dryden, writes :^ It has also been suggested that we combine our form of insurance with a provision for a benefit in the case of sickness. We tried that experiment for several years when we commenced operations, and found it impossible to conduct the business with safety and security, so we abandoned it. The Prudential of Eng- land and other industrial companies have tried sickness insurance and found it impossible. The British government considered the subject, but found this sug- gestion impracticable. Subsequent experience proved that under present conditions the operations of an industrial company must of necessity be limited to the assurance of a sum certain payable at death, while the assurance of a stipulated sum during sickness can only with safety be transacted, and then only in a limited way, by fraternal organizations having a perfect knowledge of and complete supervision over the individual members. Likewise, in attempts to carry health insurance in small locals in which the members know each other, there may be fatal weaknesses. The sharp differences in experience when small locals carry the risk is shown by the varying per capita payments. The Artisan's Order of Mutual Protection of Philadelphia published in August, 1918, in their organ. The Artisan, the experience of 65 assemblies for the preceding 'John F. Dryden, Addresses and Papers on Life Insurance and Other Sub- jects, 1909, pp. 99, 100, 31, 32. iS8 year. The average expenditure per member for all assemblies was $1.46. The average expenditure in the various assemblies ranged from 8 cents per member to $5.88 per member. 6 assemblies paid less than $0.50 16 assemblies paid from $0.50 to $1.00 26 assemblies paid from $1.00 to $2.00 II assemblies paid from $2.00 to $3.00 4 assemblies paid from $3.00 to $4.00 I assembly paid from $4.00 to $5.00 I assembly paid from $5.00 to $6.00 It is clear that such variations indicate that insurance is not dis- tributing the burden evenly. In some assemblies the cost is ridiculously low. In others, it is extremely high for the amount of benefits afforded. If a carrier does not have sufficient membership to allow the law of probabilities to work, then insurance is a mere gamble. The argument is advanced by some that industry should take up the matter of securing universal health insurance within itself. The special report on sickness insurance made by the Committee on Industrial Betterment of the National Association of Manufacturers in 1918, after recognizing the obligation of industry in helping to care for sickness of workers, said that: Prior to the consideration of a compulsory form of industrial sickness in- surance, the question of voluntary insurance should he carefully reviewed, especially the study of existing systems in operation' in many industrial and trans- portation companies. The utiHzation of establishment funds and their experience is dis- cussed under the subject of carriers in this chapter. Undoubtedly, each industry forms an ideal unit for the carrying of insurance, but as a means of universal insurance it leaves out of consideration the fact that 51 per cent of the workers engaged in manufacturing in Ohio are employed in plants employing 250 employees or less. The distribution for Ohio in 1914 is shown in the following table: 159 Establishments and Nwnher of Wage-earners by Size of Establishment , 1914' Men per establishment Number of estab- lishments Persons employed Per cent of total employees 1 to 5 . . . . 6 to 20 ... 21 to 50 . . , 51 to 100 . , 101 to 250 . 251 to 500 . . 50r to 1000 , 1000 and over Total . . . 7,557 3,048 1,470 801 663 249 103 47 17,229 34,145 47,766 56,944 104,245 84,905 72,823 92,378 13,918 510,435 3.4 6.7 9.3 11.2 20.4 16.6 14.3 18.1 100.0 Of the total workers of the state not over 30 per cent are employed in establishments large enough to have benefit funds of their own which could be established on safe insurance principles. COMPULSORY VS. VOLUNTARY INSURANCE Upon the general principle of health insurance there is Httle di- vergence of opinion. Practically everyone who has considered the matter recognizes that the distribution of the loss fom sickness by means of insurance is desirable, just as the distribution by means of insurance of the fire loss, the marine loss and the loss of other forms of property is desirable. There is no difference of opinion until the proposition is reached that such insurance should be made compulsory. Then the cleavage of opinion appears; on one side are those who believe in the laissez faire doctrine or the "let alone poHcy", and on the other side those who be- lieve that governments acting for all the people should compel certain things to be done by the individual for the benefit of himself and the community. Compulsory health insurance rests upon the propositions: (a) that sickness is a universal risk which the individual cannot measure for him- self but which can be measured for large groups ; (b) that the results of sickness are so disastrous as to make the whole subject a matter of community concern; (c) that individuals left to their voluntary choice will fail to insure, even if private agencies were available; (d) that only by compulsion is it possible to distribute throughout industry the burderi of sickness which it should justly bear; (e) that the contribution from industry and the state will provide more adequate benefits than the workers could purchase unaided; and (f) that the cost of voluntary insurance is high because of the expense of solicitation, of administra- "United States Bureau of the Census, Abstract of the Census of Manufac- tures, 1914, pp. 422, 423. i6o tion and of profits, whereas a compulsory plan can insure all auto- matically and enables the business to be conducted at a lower cost of administration. The principle of compulsory insurance is not new, particularly in Ohio, which has had compulsory state managed workmen's compensation for industrial accidents for nearly six years. The New York State Federation of Labor in its third report on health insurance says: "To prove effective, health insurance, like workmen's compensation, must be compulsory. No other plan will work." Voluntary insurance means only partial insurance of only a part of the people. It means expensive insurance for those who carry it. BENEFITS UNDER HEALTH INSURANCE The benefits which should be afforded under health insurance are: I . Cash benefits amounting to a part of the wages ; II. Medical benefits including care by physicians, surgeons, specialists, dentists and nurses, hospitals and dispensaries, and the provision of the necessary medicines, drugs and medical and surgical sup- plies and appliances; " III. Maternity benefits for women workers; IV. Funeral benefit; V. Rehabilitation, both physical and vocational. Cash Benefits Cash benefits are thought of first when health insurance- is men- tioned. Such benefits are essential because the compensation of prac- tically all wage-earners stops as soon as they quit work. It is a well- known social fact, which was emphasized over and over in the hearings before the Commission, that the majority of workers do not have enough to tide them over a brief illness of two weeks, to say nothing of a longer disability. Taking this fact into account, it is plain that if the insured person is to be kept from some form of dependence or from some ex- pensive expedient to care for the necessities of himself and family dur- ing disability, the cash benefit should be sufficiently large to help ma- terially in providing the minimum necessities of life and that it should be paid promptly. Those who care to insure for more than the minimum of cash benefits provided by the system should have opportunities for supplementary insurance through fraternals and trade unions. Cash benefits, aside from providing for immediate necessities, serve a more permanent purpose of making it financially possible for the in- sured to begin medical treatment earlier and to remain under treatment longer or until he is restored to health. Prevention and rehabilitation are thus made possible. Any limitation of benefits to 13 or 26 weeks or in fact any time i6i limitation will counteract the primary purpose of health insurance which is to prevent sickness and poverty. The tables of distribution of cases of disability by duration show that 3.0 per cent of the persons who are disabled more than one week will be disabled an additional 26 weeks or more, and that 1.2 per cent will be disabled one year or more. To aban- don the cases which exceed 26 weeks is to fail to do the most essential thing in preventing poverty or economic handicaps from overwhelming those sick persons. Health insurance legislation has frequently limited the cash benefit to 26 weeks of disability, in part because of the fear of expense. The bugaboo of chronic cases has obscured the vision of the strongest advo- cate of health insurance in this respect. Observations of cases of disa- bility among over 600,000 workers involving 131,921 cases of disability indicate that with a waiting period of seven days, an increase from 26 weeks to one year in the period for which cash benefits are payable does not double but merely increases the total compensated days by 12.8 per cent. The same table also indicates that an in- crease in the waiting period when no benefits are paid from seven to nine days will permit benefits to be paid for 11 weeks more or 37 weeks in all without any increase in the cost. By the inclusion of the longer cases the real burden of sickness would be covered and not merely that part which can be borne most easily. It is not a permanent handicap, inconvenient though it may be, for a workman to be incapacitated seven or even nine days without insur- ance payments, but it is an overwhelming handicap for a man to be con- tinuously sick for three months or more. It is certain dependence for many who are sick beyond 26 weeks. The insurance principle is not properly applied if the lesser risk is insured and the greater ignored. A system of health insurance which limits payments to 26 weeks will not prevent all the poverty created by sickness. Health insurance which cares for the long-time cases will pre- vent a larger part of the poverty directly due to sickness. Medical Benefits There are three main purposes of an adequate medical service as a necessary part of a health insurance system : I. To cover the expense for medical service, expenditures which often exceed the wage loss and compel the worker to seek medical charity or leave him badly in debt; II. To make possible the organization of preventive measures to the fullest practicable extent; III. To restore disabled workers to their original working power as completely and as quickly as possible, 11 l62 The realization of these purposes depends upon the organization of medical service, including general practitioners, surgeons, specialists, dentists, nurses, hospitals and dispensaries. It depends also upon the recognition of the proposition that if a man is to be properly insured he must be entitled to the necessary medical service, whether it cost $I0 or $500. The application of insurance principles to the risk of medical costs makes this possible. Figures show that 508 families in Cleveland, Lorain and Toledo had an average medical expense of $41.79 last year. Six of these families had expenses running over $300 each, while three had none. By insurance those who by chance sufifer most are protected, and however much the cost may be, it is already paid for by cooperation. The form of medical organization under health insurance is im- portant if these purposes are to be accomplished. In the preliminary statement made by the Commission the subject was set forth for the purpose of discussion. The propositions there presented are repeated below. All systems of health insurance in force abroad, and all proposals for health insurance in this country .provide medical benefits as a part of the insurance. A small payment in cash is made to cover the worker's loss of wages and medical care is given to restore him to health. The bijrden which medical care entails is often much more serious than the actual loss of wages and in many cases it is many times greater. If a man does not accept medical service as a charity, he finds the cost so great that he is likely to go without and allow serious maladies to develop or he is at least likely to secure the minimum of medical care with re- sulting detriment to his future welfare. He may, in lieu of medical service, moreover, turn to self-medication which results either in useless expenditure of money, or the possible formation of drug habits which prove disastrous. Moreover, the person without proper medical care is, in many forms of sickness, a postive menace to the community as a spreader and carrier of disease. From the standpoint of health insurance, it is essential that adequate medical service be provided in order that the drain upon the funds may be stopped at the earliest possible moment. A sickness which may be arrested in a day or two may, if neglected, end in complications which would keep the person on the insurance fund for months. Good business principle would, therefore, provide for complete treatment of even minor ailments in order to prevent later excessive charges. At present, in the State of Ohio there is, in most cases, no medical service connected with any of the insurance funds. A few of the establishment funds and individual plants provide emergency treat- ment which is highly preventive in character. If it is deemed advisable to organize a plan of state health insurance, then, it becomes necessary to give the most painstaking attention to the organization of medical care, including the care by physicians, surgeons.. i63 hurses and dentists, hospital treatment when necessary, and the supply of all of the medicines and drugs which may be needed in the care of the patient. Many methods have been suggested for organizing medical service under a health insurance plan. One plan is known as the panel system, by which all of the physicians who desire to practice under the health insurance act enroll themselves on a panel of doctors who may be called upon for sickness. When an insured man is taken sick he has the right to call any doctor whose name appears on. the panel. Presumably, in such cases he will select his own family physician. The bill for the services would be rendered by the doctor to the insurance carrier instead of to the patient himself. By another plan each insurance carrier would employ physicians to take care of the cases which arise. The patient would, in such a case, be required to receive medical care from the doc- tor employed by the insurance carrier. Another plan would permit the patient to select his own physician, whether he was on the panel or not. The principal problem is the method of compensation for the physi- cian's work. He may be employed on salary; he may receive so much per visit; he may be paid so much per person on his list of insured persons, regardless of the treatment received ; or the doctors together may receive so much per member, dividing this sum among themselves on the basis of visits, — a combination of these last two methods. It is also necessary to provide for the services of specialists in cases requiring special attention, whose compensation would necessarily be fixed on an equitable basis. Hospital service should also be available for necessary cases. To prevent malingering on the part of the patient, it is generally suggested that a referee doctor or board of doctors be provided for the purpose of determining when a person shall receive benefits and when these benefits should cease. It has been suggested also that the district boards and the state com- mission which supervise the whole plan should have ample representa- tion of medical men, and furthermore, that the whole organization should be coupled up with the state and local departments of health in order that the greatest amonut of preventive work may be worked out co- operatively. The Commission recognizes the very great importance of an ef- ficient medical service under health insurance which should be remunera- tive to the medical profession, promotive of the best professional practices and to the highest degree preventive in character. It is believed that with the cooperation of physicians of the state a practicable and efficient plan can be evolved. The form of medical organization, however, is not one to be fixed in advance by arbitrary statutes which are not . easily changeable. It has already been noted how widely diflferent are the medical facilities 164 of the state. This fact must be taken into account in planning an organ- ized medical service. The statute should go no further than to lay down certain broad propositions requiring that adequate medical facilities be provided to accomplish the ends in view and should leave to the State Health Insur- ance Commission the formulation of details which may be modified and enlarged from time to time. This plan will enable the physicians them- selves to take an active part in formulating the plans for medical organ- ization under which they are to work. The medical profession of Ohio can do a service to the state and to the nation by the development of plans which will give to health insur- ance, when adopted, the necessary basis for adequate medical care. The preceding discussion relates to medical care of insured workers It includes provision for maternity care of employed women, but does not include maternity care for the wives of insured men or the general medical care of wives and dependents of insured men. As a development of organized practice of medicine it is desirable to include medical care of the families of insured men. As an insurance proposition it is only less important than the insurance of the bread winner himself that the risk of the possible heavy burden of medical care for the family shall not fall entirely upon the individual but shall be distributed throughout the group. Adequate medical service is as necessary for the dependents as for the man himself and such service is seldom fully secured through purchase by the rank and file of wage- earners. The placing of part of the cost upon the employer raises some ques- tions of a fundamental constitutional character. Can the employer be required to contribute to a fund for the purpose of paying for the medical care of an employee's dependents ? That question can be affirma- tively answered if the principle of the minimum living wage is accepted. If the minimum living wage is interpreted to mean a living wage for the worker and his natural dependents, then it is clear that as a part of the wages there may be required from employers a contribution toward an insurance fund to take care of the contingencies of sickness for the dependents of employees, as well as for the employee himself. It is also possible to so apportion the relative contributions of em- ployer and employee that the employer's share will represent industry' t responsibihty for sickness among the wage-earners and that the worker's contribution will pay for the medical care of his dependents. Maternity Care Provision for working mothers at the time of childbirth is included in the medical and cash benefits outlined above. Medical benefit would include medical care and attendance during pregnancy, at confinement i65 and the necessary after-care. Cash benefit would be payable to insured mothers when unable to work because of pregnancy or confinement. Maternity provision for the wives of insured men would consist of medical care as a part of the medical care given to the dependents of insured workers, if this extension is found feasible. Funeral Benefit The extensive development of funeral benefits by industrial com- panies, fraternal orders and trade unions testifies to the importance wage- earners attach to this provision. Its inclusion as a benefit under an obligatory health insurance system would make it universal among wage- earners. Moreover, provided on this basis, it would cost the wage- earners less than under present arrangements, because expense for over- head would be shared with the other benefits and because the expensive canvassing for business and the house-to-house collection of small con- tributions would not be necessary. A benefit of $ioo payable on the death of an insured wage-earner is proposed. THE COST OF HEALTH INSURANCE No part of the proposals for health insurance is subjected to so much confusing argument as the matter of cost. Some of the confusion arises from the failure to understand the first principle of insurance and some is due to deliberate misrepresentation. It should be made clear at the outset that health insurance does not create costs. Insurance distributes costs but does not create costs. When there is a regularly recurring loss from any cause and that loss is pooled under insurance, it is not proper to speak of the premium paid as a cost. Applying the principle to the question in hand we find that sickness costs fully $80,000,000 annually in Ohio, and "that a plan of insurance merely seeks to pool the loss and to distribute it over all the people. It is plain that the cost already exists ; that at present some people bear a dispropor- tionate share; and that all people sooner or later suffer the loss of sick- ness and often in such ' severity that they are economically handicapped or perhaps overwhelmed. While it is a misnomer to designate the expenses distributed under health insurance as costs, it is necessary to determine the amount of money which will need to be raised to provide for the existing losses from sickness and the amount which each of the factors involved must pay to pool the burden. Allowing for a waiting period of seven days and the consequent elimination of minor illnesses, and providing for the payment of benefit during 52 weeks of disability, each worker on the average would be compensated in an obligatory system for at least 6.8 days. With a fixed maximum compensation of $10 to $12 a week, but in no case exceeding i66 two-thirds of the wages of the insured jperson, it is a simple matter to de- termine the total cost for any given number of workers. For illustration, let us estimate the total of industrial workers at 1,000,000. The total number of days for which compensation would be paid amount, there- fore, to 6,800,000. At the maximum payment of $12 a week, this would amount to a total of $11,700,000. This amount would be somewhat re- duced because many workers would not be entitled to the maximum of $12 a week. For example, a worker earning $15 a week would be entitled to a maximum of $10 benefits; a worker earning $12 a week would be entitled to a maximum of $8 a week benefits, etc. This reduction would make an increased margin of safety. The cost of medical care is not so exactly determinable as the amount of cash benefits, because of the lack of experience over a period of years. Moreover, the organization of medical service under the plan would alter materially the medical costs, on the one hand increasing them by pro- viding adequate care to all insured persons and on the other, materially reducing the costs by prevention and by the elimination of waste througli more efficient organization of the whole medical service. The experi- ments which have been tried are not, therefore, exact criteria under an entirely new system of organization. In the report of the United States Commission on Industrial Rela- Lions it is estimated that medical care of each worker costs $6. Warren and Sydenstricker accept this figure in their report on health insurance published by the United States Public Health Service. The four years' experience relating to sickness, and non-industrial accidents of the Milwaukee Street Railroad and Light Company which has given medical care to its men for a number of years follows: the combined membership for four years equals 10,567 men for one year. The home calls by physicians numbered 7,546 or 710 per thousand. The office calls totalled 39,243 or 3,713 per thousand members. The number of major operations performed was 150. The number of minor opera- tion was 305. The total value of medical service was $51,393, or nearly $5 per member. Since 19 17 the medical service has been extended to the dependents of employees. In 1917 there was an average of 3,029 members, and the total value of medical service to men was $16,857. During the same year the value of services to women and children de- pendents was $15,756. From these data it appears that the cost of medical care for dependents nearly equals the cost of medical care for men alone. These figures represent the regular charges for medical service based upon prevailing rates. A fair margin of safety should be allowed in these figures to provide for more complete medical service than has been heretofore provided and for the extra hazards of many less desirable risks when a universal system is established. 1 67 Making due allowance, it appears that medical service for employees only can be furnished under present conditions for $6 to $7 per employee and that the extension of medical service to dependents of employees will approximately double the average expenditure for any large group. A total medical expenditure of $12,000,000 to $14,000,000 appears a fair estimate for one million employees. A death benefit of $100 granted insured workers would cost a maxi- mum of $1,000,000 a year for 1,000,000 insured persons. To this should be added the cost of administration, both by the state and the local carriers. Upon the basis of American establishment funds, the experience of the state fund for workmen's compensation and for- eign health insurance experience, the administration is estimated at 10 per cent of the cost of benefits. This, added to the expenditure on bene- fits, makes a total of $29,920,000 which will need to be collected for the purpose of pooling the losses from sickness for a million workers. CARRIERS There are several methods of carrying the insurance under a compulsory system. L The employer and employee may be compelled to insure against sickness of the employees, but they may be left free to select or establish their own carriers, as is done in several workmen's compensation acts. IL A state fund may be created in which all might be required to insure as in the case of accidents under the workmen's compensation law of Ohio. in. Local public carriers might be established to manage the in- surance for a given geographical area under the supervision of a state health insurance commission. IV. Existing carriers of health insurance, such as fraternals, trade unions and establishment funds which are mutually and democratically managed might be approved as carriers, under standards fixed by state health insurance commission. Local public carriers could be or- ganized to take care of those not in other carriers. The first of these methods is a simple but an expensive, way to handle the matter. It places the employers and employees at the mercy of ex- isting carriers and commercial health insurance companies in which costs are high and must necessarily remain so as long as the companies con- duct a competitive business. The larger establishments would probably form special benefit funds and many employees would join fraternal and trade union sick benefit funds. A large part would be compelled to seek insurance from the commercial companies. This plan with its geograph- ically scattered membership would not permit the organization of an ef- ficient medical service which is necessary under a complete health in- i68 surance system. The expense of conducting the business upon a com- petitive basis would greatly increase the cost to the insured. The second plan, a state insurance fund, was advocated by several persons who appeared before the Commission. The splendid success of the Ohio state fund for workmen's compensation was undoubtedly the reason for proposing a state fund for health insurance. The success of the Ohio state fund for accident insurance should be given due weight in evaluating the merits of plans for carrying health insurance. But there are special features about health insurance which should be taken into consideration in developing a plan of carriers. Health insurance has been best managed on a mutual basis in societies in which the insured know each other. These two features are characteristic of fraternal, trade union and establishment funds. The experience of all countries is the same under a voluntary system and also under compulsory state insurance. Almost universally local carriers are used in systems of obligatory insurance. There also have been combinations of local carriers into a single community fund, as in Leipsic, but a single national or state fund is the exception. The difficulty of organizing adequate medical service under a state fund is also a serious drawback to a single state fund. But the chief objection rests upon the special necessity under health insurance of placing responsibility upon the insured for proper and careful management in order to prevent malingering. It appears necessary,' however, that every carrier reinsure in a state fund for special hazards, such as epidemics, long continued disabilities and excessive average ages, so as to equalize the burden and to make the carriers more stable. The third method, exclusive reliance upon local public carriers, would probably be the advisable method if it were not that several types of carriers with experience and prestige behind them exist, which should be utilized. The local public carrier would give the advantage of uni- formity and would simplify the administration. Experience and logic dictate, however, that existing carriers should be utilized so far as pos- sible in connection with local public carriers which would care for those not otherwise insured. The fourth method, the combination of certain existing carriers with local public carriers, appears to have the best claims from many points of view. The carriers suggested in addition to the public societies are fraternal organizations, trade unions and establishment funds. The terms on which they should be approved include the requirement that they be mutually and democratically managed so fas as their sickness benefits are concerned. The best thought on the subject inclines strongly toward the third method, namely to the selection of two types of carriers, establishment funds and local public mutuals as the main carriers. By limiting the cash benefits provided by these carriers to a maximum of $io or $12 a week 169 the fraternals and trade unions would be used on a voluntary basis by all who might wish to increase their cash benefits beyond those provided under the law. This plan has been embodied in the bill for health in- surance introduced in the New York legislature and is advocated by the New York State Federation of Labor. In explanation of this plan its Committee on Health says :^ The health insurance bills that have been introduced into the legislature here- tofore have taken into consideration that a very large number of the wage- earners are members of fraternal organizations. The earlier measures made these fraternal organizations a part of the administration, but provided that the sick wage-earner — no matter to how many societies he might have paid dues — should not receive benefits amounting to more than his wages. Placing the fra- ternal organizations in the system presented a very involved proposition because it meant a rearrangement of all their sick beneiit rates. That is, where they paid, as with the Moose, $7, they would have been obliged to rearrange their rates so that they would pay as liberal benefits as the health insurance measure contem- plated. But so far as the trade unions were concerned, there was an even greater objection to health insurance as originally planned. With benefits equal to two- thirds of wages the trade unions could not maintain their own sick funds, it was feared. They would also have to rearrange, to a very great extent, their systems of sick benefit payments in order to agree with what was proposed in the earlier health insurance bills. Your committee felt that these objections would remain as long as the fra- ternal organizations and- trade union funds were a part of the system. In the course of its many conferences your committee found what it con- siders a solution. We believe that the fraternal organizations and trade union sick benefit funds should not form a part of the health insurance system,- but that they should be left free to insure their members for whatever benefits they desire and not for the benefits set out in a state health insurance measure. Your committee also believes that there should be no restriction on the amount of sick benefit a worker may draw from his fraternal or trade union funds. But it believes that the maximum cash sick benefit, as far as the state law is concerned, should be limited to $8 per week. That is important, because reducing the max- imum cash benefit of the state system to $8 makes the maximum weekly wage on which the state assessment is based but $12. That is, a man earning $25 a week will be assessed on his wages up to $12; all over that would not be subject to any assessment. What this proposition which your committee has worked out will do is this : The payment of a maximum benefit of $8, based on a wage assessment of but $12, will enable the trade unions to continue their sick benefits just as at. present. The only difference would be that if a member of a union paying $5.00 a week sick benefit were insured in a fund under the proposed measure, he would draw $8 in addition to the $5 from his union, or $13 in all. If he was also a member of the Moose, he could draw $7 more from that, making $20; and if in addition he was a member of the Eagles he could draw $7 more, or $27, and so on. So under this new bill there is no impairment of his right to sick benefits in his trade union, or in his fraternal organizations. Nor will the fraternal organiza- tions and trade union sick benefit funds be obliged to change their sick benefit rules in any way. 'Health Insurance, Official Endorsement of the Nezv York State Federation of Labor, 1918, pp. 5, 6. 170 The difficulties suggested by this report and the further difficulty of organizing a proper medical system to cover all four types of carriers are the controlling factors leading to^ the choice of the two carriers, establishment funds and public mutuals, as the carriers of the required insurance, with opportunity for the fraternals and trade unions to con- tinue and extend their health insurance in the form of cash benefits. REHABILITATION The toll of persons partially or completely disabled by sickness and accident each year is enormous. Ohio industries reporting to the In- dustrial Commission reported 159,000 accidents during 1917 to the Claims' Department. The number of persons partially or completely dis- abled by sickness and by accidents outside of employment is not known because no reports are required. Altogether, 6,324 deaths in 1916 were the result of external causes. Medical service under the workmen's compensation act prevents much serious disability and restores a large proportion of the injured to full capacity as workers. But there are thousands who are not restored who might again become productive workers and might be saved from dependency if a complete process of rehabilitation were in operation whereby the physical man would have the opportunity to be restored as far as possible, and whereby the man would be given a chance for vocational training or retraining so as to fit him for some work^ which he may be able to do. In the case of persons disabled by sickness and non-industrial acci- dent almost nothing is done for rehabilitation, except such as the man himself with his depleted resources is able to buy, or such as charity is equipped to give. So it happens that thousands are cast on the scrap heap every year because they are no longer able to do the work of their trade and because no provision is available by which they can, in the first instance, be rehabilitated physically, and in the second, rehabilitated voca- tionally. The rehabilitation or retraining of industrial workers should be carefully studied and steps should be taken to take advantage of the ex- perience which is now being developed in Europe, Canada and the United States in the rehabilitation and retraining of crippled soldiers. It is true that attention should be drawn sharply to the necessity of human salvage and that disability is socially bad, whether incurred by the wounds or disabilities of war or of industry. W. L. Mackenzie King has stated the case clearly in his book Industry and Humanity, saying:* The losses which still arise in industry from preventable causes are enor- mous. Frightful as are the los.ses in war, they are paralleled by sacrifices in industry of which the world takes little or no account. Indeed, the horrors of war should rouse us to a consciousness of the horrors of industry, for they are *W. L. Mackenzie King, Industry and Humanity, 1918, pp. 323, 324. 171 the saipe. Death by the explosion of a shell in battle is no different from death by the explosion of dynamite in a mine. The loss of a leg, of an arm, of an eye, is the same whether incurred in a factory or in a fort. Tuberculosis is tuber- culosis whether contracted by the cutting of granite or in a trench. Poisoning is just as painful and just as fatal when it comes from white lead used in plumbing as from enemy gases. It is questionable if war has any diseases more hideous than some from which men and women in industry have suffered and died. Exhausted nerves, wasted energy, depleted vitality : these are not the peculiar inheritance of armies. Few industries have not had their hosts of shattered humans. MALINGERING The problem of malingering must be understood and dealt with by the hospitals and physicians. We know very little about malingering at present. The problem has been little studied in this country. While we have had many instances under personal accident and employers' liability cases, it is only since workmen's cornpensation became general that the problem has become a social one. Malingering results from a desire to escape work, to excite sym- pathy or to reap pecuniary advantages. It should be carefully dififer- entiated from disease due to mental or nervous derangement. It is the problem of hospitals and doctors to determine whether it is fraud or disease and to counteract the fraud and understand the character of the disease. The war is teaching many lessons. We are learning that much which might have been called malingering is not a conscious simu- lation of disablement. - Sir John Collie, the leading English authority on the subject, recently said in the Dublin Review: As it was known that it was possible for a person to be really ill from merely witnessing an accident although no physical injury^ was sustained, and that a serious derangement of the nervous system, involving marked loss of function, could result from emotional causes alone, the soldier with no apparent wound or injury to show to justify his condition became the object of greater solicitude than otherwise might have been the case. The fear that obligatory health insurance will increase malingering is however an exaggerated one, due in part tO' failure to understand the true nature of malingering. The tendency of popular psychology to exaggerate the extent of malingering was evident in Great Britian in the days immediately following the coming into operation of the British national insurance act, days when the amount of sickness, especially among women, appeared higher than that which the actuaries had an- ticipated. The cry went up "malingering" A thorough and notable in- vestigation ,was made.^ The findings disclosed that the excess was in part due, to administrative difificulties such as lack of cooperation from the medical profession in signing patients "off the funds" ; in part to the psychological reaction where over-insurance existed; in part to the lack " Great Britain, Departmental Committee on Sickness Benefit Claims under the National Insurance Act, 1914, Cd. 7687. 172 of understanding of the nature of insurance, especially among v^omen; in part, especially among women and in certain societies, to a very genuine excess of sickness above the expected rate. In other words, malingering did not play the important role to which popular thinking assigned it. Efforts to establish malingering as a result of an obligatory health insurance system are usually deductions from experience with workmen's compensation or are based upon the increased number of sick days per person insured in Germany and Austria or upon the higher sickness rates during the periods of unemployment. The usual inference that insurance has increased sickness in Germany, Harris explains :" . . fails to take account of the fact that it refers to the number of days for which benefits were paid and does not mean the actual duration of sickness. Thus the law of 1902 increased the minimum benefit period from thir- teen to twenty-six weeks and included sexual diseases in the class entitled to benefit. . . It will be noted, however, that since 1904 the average duration of a case has remained fairly constant. It is not, therefore, a valid deduction to infer that this increase is due to malingering. Moreover increases in days compensated per member are not con- fined to compulsory insurance; they are found in leading organizations providing insurance "on a voluntary basis, such , as the Manchester Unity of Odd Fellows in Great Britian, the Australian and New Zealand so- cieties, the Cigar Makers' Union, the great railroad benefit funds and others in this country. Increased sickness during periods of unemployment has little more substance as a proof of wholesale malingering. Charts kept by the, Lon- don Hospital plotting the state of the labor market and the sickness that comes to its doors for treatment show that during periods of unemploy- ment real sickness increases. This evidence is further substantiated by the lowered sickness rate during the war among the 14,000,000 persons insured under the national insurance act of Great Britain, — a change due in part, as the commissioners admit, to rising wages, steady em- ployment and consequent better living conditions. Malingering is not a new problem created by health insurance, but health insurance administration should profit by the experience con- cerning it. The extent of malingering is exaggerated for political effect. At the worst only a fraction of one per cent are fraudulent malingerers. In two thousand cases of suspected malingerers sent for special examination in England, Sir John Collie found 25 per cent able to go to work, which would have been an insignificant percentage of all the in- jured workmen from whom the two thousand cases were selected. The situation should be met by a new type of diagnosis. Even a slight 'See Appendix C, "Sickness Insurance in Germany," by Harris, for fuller information. 173 amount of malingering has a bad effect upon the morale of the insured people and is destructive to the few who fraudulently practice it. Hos- pitals have had much experience in the prevention of hospitalization among patients. That experience will be valuable in handling the same problem under health insurance. PREVENTION VS. INSURANCE The investigations made for the Commission have given due atten- tion the problem of sickness prevention and recommendations of far reaching character have been made for immediate legislation. The wis- dom of large expenditures for the most thorough plan of health organiza- tion for the prevention of disease and the promotion of health has not been questioned by a single witness before the Commission. The issue of sickness prevention should not, however, be confused with the issue of health insurance. Sickness prevention and health in- surance are not antagonistic. After sickness prevention has done all that the most optimistic can hope for, there remains the problem of dis- tributing the remaining burden of sickness which will still fall crush- ingly upon some people just as it does at present. Even assuming that 40 per cent of sickness will be prevented, there remains 60 per cent which will fall upon the weaker elements in unequal amounts. The family which suffers three months' loss of wages and $300 of medical expense at a single blow is no better off because the total amount of sickness has been reduced 40 per cent. Insurance is designed to cover extraordinary losses and such losses will unfortunately occur. The National Industrial Con- ference Board has recognized this in its pamphlet on Sickness Prevention or Sickness Insurance in which they argue for the prevention of sick- ness.'^ Realizing the close relationship between national efficiency and health, the National Industrial Conference Board has attempted in this brief report to em- phasize the enormous burden which sickness and physical disability place on society and industry and the imperative necessity for a thorough study of the practical possibilities of a program of sickness prevention with a view to its speedy adoption as, a national policy. Yet this should be done without prejudice ■ to the principle of compensation to the extent that its justification may be demon- strated. Obviously, however, with sickness prevention once established as a national policy, and with an efficient system of national health supervision, the necessity for resorting to some form of sickness insurance or compensation would be very greatly reduced. Measures of prevention have been in operation for years and much has been accomplished, yet we still speak of the losses as "appalling." An extension of health measures will reduce sickness and disability still further and yet we shall find that an awakened social conscience will un- ' National Industrial Conference Board, Sickness Insurance or Skkness Pre- vention, 1918, p. 2. 174 cover more and more of the "appalling" losses which we do not now even recognize. There is, for example, the whole problem of rehabilita- tion of disabled persons. Down to the time of the great War practically nothing was done for the rehabilitation of cripples. There is now an awakened understanding of this social problem and we may expect to see the attack spread to every phase of disability, whether caused by war, accident or sickness. Health insurance will profit by every act of prevention and re- habilitation and while these are not primary functions of insurance, yet business judgment as well as humanity dictate that health insurance shall help to organize measures of prevention and rehabilitation so far as possible. The combination of prevention and insurance is the goal to be sought. The discussion of the one versus the other is futile. That prevention can become a funtion of .insurance is abundantly demonstrated by the experience of public and private insurance carriers. The passage of employers' liability and workmen's compensation laws has brought on a nation wide "safety first" campaign, while several of the states hold state safety conferences regularly. There is a deep and ^pervading interest now in accident prevention. Fire insurance com- panies have been largely responsible for the organization of fire pre- vention organizations and for the passage of fire marshal laws. The Metropolitan Life Insurance Company spends several hundred thousand dollars annually on public health nursing for its industrial policy-holders. Life insurance companies contribute liberally to such public health move- ments as the Life Extension Institute and the American Public Health Association. The motive is not philanthropy but business. Prevention saves losses which would otherwise have to be paid. Why prevention would not become a necessary part of social health insurance when it is a recognized instrumentality in private insurance business is beyond explanation. THE MOVEMENT FOR HEALTH INSURANCE IN THE UNITED STATES" No American state has enacted a health insurance law. The agita- tion did not begin until after workmen's compensation insurance had gotten well under way. The logical connection between health insruance and workinen's compensation was imrnediately seen by the American Association for Labor Legislation which created a special committee. This committee formulated a tentative bill, modified from time to time, which has served as a standard. Bills have been introduced in several legislatures, beginning in 1916. Commissions have studied the question in Massachusetts, California and New Jersey, while commissions are now at work in Pennsylvania, Connecticut, Illinois, Wisconsin and Ohio. ° See Appendix A., "Health Insurance Movement in the United States, by Com- mons and Altmeyer, for fuller information. 175 The Massachusetts commission of 1917 reported by a majority in favor of compulsory heahh insurance. The second commission reported in 1918 by a majority adversely. New Jersey reported in 1918 in favor of health insurance, as did California in 1917. The other states report during the present legislative session. California had a referendum on a constitutional amendment at the last election when the amendment enabling the legislature to enact health insurance legislation was defeated by a vote of more than two to one. Widespread interest has been aroused in the subject of health in- surance and many national, state and local organizations of employers, employees, physicians and social workers have taken up the matter by resolutions or by special committees. The American Federation of Labor has a special committee working on the subject at the present time. Other national organizations which have given attention to the subject are the National Association of Manufacturers, the National Industrial Con- ference Board, the American Medical Association, the American Hos- pital Association and the National Fraternal Congress. The governors of three states, Governor McCall of Massachusetts, Governor Smith of New York and Governor Edge of New Jersey, haV& strongly urged the adoption of health insurance and the New York State Federation of Labor prepared and fostered a comprehensive health in-' surance bill at the last legislative session and is conducting an active campaign for it at the present session. The establishment of the war risk bureau and its widespread appli- cation of the social insurance principle in the insurance of soldiers and sailors against death and disability has given the most authoritative proof of the social value of such an institution. Hearings are now in progress in Congress as to the desirability of extending the war risk insurance to include civilians and to cover the risks of sickness, disability, unemploy- ment and old age. One can scarcely review the progress of only ten years without recognizing the tremendous sweep of the idea of social insurance and the certainty of its future expansion. CHAPTER Xi HISTORY OF HEALTH INSURANCE The history of health insurance, that is, insurance for temporary iisability, is a long one. Only an outline of its more recent evolution lue to the increasing participation of the state in order to secure more .dequate protection for workers will be attempted. Governmental par- icipation in health insurance, founded by private initiative, has developed long two main lines. The main development has been along the line of tbligatory insurance jointly supported by the worker, the employer and he state. Somewhat subsidiary has been the more restricted growth if 'state subsidized voluntary insurance. Health insurance in one of hese two forms is found among the leading industrial nations of Lurope. I. OBLIGATORY INSURANCE Germany Health insurance through private agencies has been the fore-runner if more comprehensive systems. Thus in Germany, previous to the pas- age of the obligatory health insurance act of 1883, guilds, establishment unds and mutual aid societies insured in 1876 against sickness an istimated membership of 2,000,000. By the side of this there grew up n Germany a body of legislation authorizing local authorities to require nsurance of special groups of employees or to require employers to pro- vide insurance. A parallel movement today is the obligatory insurance or certain groups of workers, such as the miners, seamen and railroad :mployees in France, railroad employees in Italy, seasonal workers in )enmark, etc. The early German developments were combined into a comprehen- live uniform national system by the insurance act of 1883. This act xtended the principle of compulsion to workingmen and technical em- iloyees in mines, quarries, factories, and other industrial concerns, af- ecting both the workers and their employers who were required to de- ray part of the cost. Side by side with the voluntary agencies which irere allowed to continue, new organizations formed along geographical tnes, called local funds, were established to administer insurance. Mini- num benefits of medical care, cash payments during disability and in ase of death were prescribed. Two-thirds of the expense was to be (176) ^17 borne by the worker, one-third by the employer and the state assumed the cost of central supervision. Amending acts have considerably enlarged the scope. Only ten years after the first law was passed, it was decided to include new groups of employees. The acts of 1892, 1900, 1903 and the code of 191 1 ex- hibited a similar trend, increasing the scope of the act from a narrow application embracing 10 per cent of the population in 1885 to a broad one covering 20.9 per cent in 1908 and to a still more inclusive one estimated to embrace 30 per cent of the total population in 191 1. This movement was accompanied by an extension of benefits : the act of 1903, for example, increased from thirteen to twenty-six weeks the period for which cash benefit was payable; raised the basic wage upon which the cash benefit is calculated and increased, from four to six weeks, the period for which maternity benefit is payable. Thirty years' experience has demonstrated the value of the various carriers. Whereas at the outset 20 per cent of the workers were in- sured in mutual and state mutual aid funds, organizations resembling British friendly societies, the proportion thus insured has steadily di- minished until in 1910 the persons thus insured constituted only 7.4 per cent of the total. The factory or establishment funds have maintained their proportion of those insured. On the other hand the local funds, the carriers especially created by the act of 1883, which at the outset insured 35.7 per cent of the workers, in 1913 insured 57 per cent of the total. The code of 191 1 reduced the number of types of carriers and discriminated against the building funds and mutual aid funds, carriers insuring but small proportions of the workers. This was done in an effort to concentrate the insured in the local and the establishment funds, — the two most successful types. Existing arrangements automatically insure the workers in the local or rural fund of the district, unless a special fund for the establishment has been created or unless the worker is a' member of a substitute fund. The local and rural funds are ad- ministered by the insured workmen and their employers, — their re- spective shares in the control being proportional to their respective con- tributions. This mutual democratic administration enlisting the interest of the workers and employers is supervised by a central government authority. The act has always been financed on the so-called average premium system, the assurance under compulsion of a regular influx of young lives being a practical substitute for actuarial reserves. Under this system yearly contributions are sufficient to cover the expenses of the year and to provide a small surplus from which emergencies may be met. The principles of this legislation have influenced greatly the con- tinental development of health insurance. 12 178 Austria Austrian legislation dating from 1888 covers, with minor excep- tions, all workmen regardless of their earnings and administrative offi- cials earning less than 2,400 crowns ($487.20) a year, who are employed in factories, mines, quarries, shipyards, building and transportation. For the 3,694,000 workers thus insured it provides free medical treat- ment, inclusive of medicines and appliances ; a cash benefit equal to 60 per cent of the wages of day laborers payable for not more than twenty weeks in a year during disability due to sickness or accident; a benefit of like amount for the four weeks following confinement and in case of death a cash payment equal to twenty times the daily wage. . Pro- posals for amendments include extending insurance to other groups and increasing the benefits. The cost is met two-thirds by the workers and one-third by the employers; the joint contribution being practically lim- ited to 3 per cent of wages. These contributions cover the current ex- penses and accumulate a small surplus from which to meet emergencies. Insurance is carried, as in Germany, by voluntary agencies, such as the guild, establishment and mutual aid funds, all of which had developed previously. These are supplemented by special types of carriers, the district funds, organized to cover an entire district and managed by their members under state supervision. All persons not members of other funds automatically are insured in the appropriate district fund. The number of building, guild and mutual aid funds has increased although the membership has not increased proportionally, so that individually funds of these types have a smaller average membership. The district funds, on the other hand, are fewer in number than previously, but their total membership has increased from 35.6 per cent of the insured in 1890 to 43.1 per cent in 1912. They are, on the average, numerically stronger than at the outset ; and as a group they insure more persons than any other type. The success of the district funds and the complexity of ad- ministration necessitated by permitting so many types of carriers has led to governmental proposals to restrict the other types and to en- courage the district funds. Hungary The Hungarian sickness insurance law passed in 1891 and codified in 1907 applies to all persons earning less than 2,400 crowns ($487.20) a year employed in industrial establishments, mines, quarries, construc- tion, transportation and commercial establishments. By the act of 1907 employees in government monopolies and those engaged in state and city undertakings were included. The benefits are similar to those provided in Austria, with the important addition of free medical and obstetrical aid for the family of the insured. The cost, varying from 2 to 4 per cent of wages, is shared equally by worker and employer. The adminis- tration, as the result of the amending act of 1907, is consolidated into 179 two national funds which replace the local funds. This is the first and most important instance of state administered health insurance. Luxemburg The principles embodied in the sickness insurance legislation of Luxemburg, dating from 1901, are very similar. The system includes all employees working for wages or salaries below 10 francs ($1-93) per day or 3,000 francs ($579) a year who are employed in transportation, mines or quarries, postal, telephone or telegraph service, in factories, building and construction and commercial establishments. Free medical aid, cash benefits equal to 50 per cent of wages payable for thirteen weeks of disability, maternity benefit payable for at least four weeks and a funeral benefit equal to twenty times the daily wage, are provided. Two- thirds of the expense is borne by the worker and one-third by the em- ployer. The insurance of some 37,000 insured persons is carried by three authorized types of carriers, — mutual aid funds, establishment and dis- trict funds. As in Germany and Austria, the mutual aid funds carry but a small percentage of the total, amounting to only 3 per cent in Luxemburg. The district funds insure 38 per cent while the establish- ment funds, insuring 59 per cent of the total, are the dominant type. Norway Norwegian legislation of 1909 is the result of nearly twenty-five years' discussion. It includes, without regard to occupation, all em- ployees over fourteen, who earn less than $321-375 annually according to location. It provides medical care to both the insured and his imme- diate family ; cash benefit equal to 60 per cent of wages payable during not more than twenty-six weeks of incapacity in a year ; cash maternity benefit payable for six weeks and in case of death a funeral benefit equal to twenty-five times the basic wage up to a prescribed maximum. The cost is distributed in a novel manner : the insured worker bears six- tenths of the expense, the employer one-tenth, the commune one-tenth and the state two-tenths. The standard carrier is the district fund man- aged by the insured, their employers and a representative of the com- mune and supervised by the state insurance institution. Mutual organ- izations not operated for profit, such as establishment funds, may be authorized to carry insurance. Servia The sickness insurance legislation of Servia, embodied in the gen- eral industrial code of 1910, is applicable to persons employed in industry, mining, transportation and trade. The specified benefits embrace medical care and medicines for the insured and their families ; sick benefit equal to at least one-half the daily wage while the patient is compelled by i8o medical advice to remain in bed ; and a funeral benefit. The cost is shared equally by employers and workmen. To this the state contributes an- nually 100,000 dinars ($19,300). In line with European practice in- surance is carried by self-governing associations of workmen and em- ployers and may be carried by approved miners' and factory funds. Great Britain^ The British national insurance act of 191 1 marks a distinct departure from the principles embodied in continental legislation. Provision is made, as in other countries, for medical care and for a cash benefit dur- ing a maximum of twenty-six weeks of disability. Unlike European systems, the rate of benefit is not graded with reference to wages but a ' uniform benefit at a specified rate is established for men and for women. Maternity benefit, instead of being paid weekly in amounts proportional to wages, is commuted to a lump sum payment. No funeral benefit is provided. Unlike leading continental systems, a disablement benefit to provide for cases of prolonged invalidity is included in health insurance. This variation is attributable to the fact that on the continent provision for invalidity frequently is included in systems of old age insurance; whereas in Great Britain where old age pensions were already in opera- tion it was logical to include provision for invalidity in the new measure. The cost of insurance is divided among workers, employers and the state in varying proportions for men and women. The contributions, instead of being graded with reference to wages, are fixed by law at uniform rates, with a sliding scale for those manifestly underpaid. Even more important than the uniform benefits and contributions, is the basis upon which they are calculated. The British system, unlike the continental insurance, is based upon actuarial reserves. The 3d. (6 cents) and 4d. (8 cents) paid by the workers and supplemented by employers and the state, are the contributions which, if paid from six- teen years of age throughout life by women and men respectively, it is estimated, will be more than enough to pay for the benefits of early life thereby accumulating a reserve sufficient to meet th-e heavier sickness claims of middle life. Contrasting with this is the average premium plan. In this the over-payments of the present younger members constitute the source from which the heavier claims of older members are met. The present younger generation, when they grow older, will in turn have the excess above their contributions met from the surplus of the incoming generation. But the unrestricted freedom in the selection of the carrier granted by the British system does not guarantee each society its due proportion of young lives, so that the adoption of the average premium plan would not have been practical. 'For more detailed discussion see Appendix Bj "Compulsory Health Insur- ance in Great Britain," by Edith Abbott. i8i The British legislation is unique in permitting unlimited choice of carrier and in relying almost exclusively upon voluntary agencies as insurance carriers. Great Britain encouraged insurance in existing agencies and the formation of new societies modeled upon the old. Instead of creating for those not already insured, strong carriers de- signed to play a leading part in the administration of health insurance, as a temporary expedient, Great Britain created the deposit contrib- utors' fund. From this fund each depositor may draw out in benefits only the amounts standing to his personal credit less administration expenses. This catchall, insuring in 1914 but 472.272 out of 13,860,054 Of 3.4 per cent of the insured persons, is the antithesis of the conti- nental policy. Still another deviation from general continental practice is the separation of the administration of cash benefits from that for rriedical benefits. Cash benefits are provided through approved societies; med- ical and sanatorium benefits are administered by local committees. This variation is in part the result of free choice of carrier which makes it expensive for societies to administer medical benefits for a widely scat- tered membership. The administration of medical care, distinct from that of cash benefit and conducted along local lines was the plan adopted. These departures from established principles have been dwelt upon because their success is on trial for the first time. Russia The following year, 191 2, Russia was swept into the current. The act is of limited application, including workers employed in fac- tories, mines, metallurgical establishmlents, inland navigation, and street and local railways, in which twenty or more persons and mechanical power are employed. If no power is used the act applies only to workers in establishments employing thirty or more persons. Sick ben- efits, payable for not more than twenty-six weeks, must equal at least half the wage in the case of married workers, but may vary from one- fourth to one-half wages in the case of single employees. A cash maternity benefit, varying from one-half to full wages, is payable for two weeks before and four weeks after confinement. In case of death, a funeral benefit varying from twenty to thirty times the daily wage is paid. Workers bear 60 per cent of the expense, employers 40 per cent. The admnnistration is entrusted to funds formed for one or for several establishments and controlled by the workers and the employers. The employers contribute but 40 per cent of the cost and control two- thirds of the delegates and directors, while the workers have but one- third of the total representation. Government supervision is provided. Medical care is not included in the sickness insurance provision because employers of factories and mines are required, in accordance with a law of 1866, to furnish free medical aid for their employees. l82 Roumamia Health insurance legislation of Roumania, dating from 1912, is part of a comprehensive act providing insurance against industrial acci- dent, sickness, invalidity and old age. Health insurance embraces all workers in industry, mining and construction. As benefits it provides: medical aid and drugs; cash sick benefit payable for a maximum of sixteen weeks, equal to 50 per cent of wages in the case of workers with dependents and 35 per cent if there are no dependents; cash maternity benefit for six weeks following confinement, to which there is added a nursing benefit in appropriate cases. The entire expense in accordance with rates of contribution prescribed by law is borne by the workers. The insurance is administered through guild organiza- tions and such agencies as establishment funds, provided they are approved by the central office. Netherlands The Netherlands in 191 3, after prolonged consideration, passed an act for obligatory health insurance applicable to all workers earning less than $300 to $600 annually according to locations, with some minor exceptions such as casual workers and domestic servants. The act provides cash sick benefit varying from 50 to 90 per cent of the average wage and is payable for not more than twenty-six weeks ; a cash benefit of like amount during incapacity due to pregnancy; and for incapacity due to miscarriage (confinement), a cash benefit up to full wages is granted. The act provides no funeral or medical benefits. The omis- siion of medical benefit is due to the existence of a large amount of medical insurance. The expense is shared equally by employer and worker. Administration is in the hands of district organizations jointly managed by the workers and em,ployers under the presidency of a gov- ernment appointee. In addition funds democratically managed and not operated for profit may be authorized to carry insurance. Both types of carriers are under strict government control. II. SUBSIDIZED VOLUNTARY INSURANCE Fr ounce In 1852 France applied the principle of state subventions to mutual aid societies providing sickness, invalidity, old age and life insurance. Subsidies are granted for the various purposes of the organizations, that for sick benefits being 827,000 francs ($165,400) in 1903. The adult active membership of the subsidized societies numbered 2,951,000 persons in 1907. i83 Sweden Sweden, in 1891, promised a governmental subsidy to registered societies meeting specified requirements and submitting to government supervision. The subsidy based upon membership amounted in 1892 to 3.2 per .cent of the expenditures. In 1897 and 1899 this w^as sub- stantially increased so that the state contribution varied from 6 to 9.6 per cent of the expenditures. After twenty years of subsidy granting the members totaled 652,000 which, when duplicates are omitted, rep- resented not quite 10 per cent of the total population. The benefits were small, — for example, the amount spent on medical care repre- serbted but 2 per cent of the total expenditures. In 1910 the subsidy was again increased, this time to societies meeting the higher standards established by th6 law of 1910. To increase the medical provision a subsidy of one-fourth the expenditure upon this item was granted, up to a specified maximum per member. Denmark In 1892 Denmark inaugurated governmiental subsidies to mutual aid societies which registered under the law and subjected themselves to governmental supervision. To obtain recognition and a subvention, a society must be composed of workmen or others of small income; must provide free medical aid for members and children under fifteen ; and a cash sick benefit not less than 40 ore ($0,095 cents) a day for a minimum of thirteen weeks. Public assistance is generous; the com- bined subsidy of state and commune in 1914 equalled 31 per cent of the total expenditure and was almost half the contribution of the in- sured. Under this liberal state aid the members insured have constantly increased until in 1914 there were 843,244 insured members, constitut- ing 30 per cent, of the total population. In 1894 Belgium provided a small state subsidy to mutual aid societies. The 3,300 associations receiving a state subvention in 1907 embraced a membership of 400,000, one- third of the wage-earners or 5 per cent of the total population. The -success has not been as great as was hoped for and in the spring of 1914 just before the outbreak of War a measure for obligatory insurance had passed one chamber of the legislature. Switzerland The Swiss law of 191 1, described as "the best of the voluntary subsidized systems" goes further in establishing uniform benefits. Sub- sidies are granted to mutual societies not operated for profit which conform to the prescribed standards. Recognized societies must pro- i84 vide: at least twenty-six weeks' medical aid or a cash sick benefit of not less than one franc ($0,193) ^ ^^YJ ^ six weeks' maternity benefit, and a four weeks' nursing benefit. Subsidies except for maternity and nursing benefit are dependent upon the extent of benefits granted and the number of persons insured. In the case of maternity and nursing benefit the state grants a subsidy of 20 francs ($3.86) for each benefit provided. A unique feature of this law which went into effect in 1914. is that individual cantons and even communes may make its provisions compulsory. Insurance already has been made compulsory by four cantons. CHAPTER XII MATERNITY INSURANCE IN EUROPEAN COUNTRIES Public interest in maternity insurance, which will enable the mother to take needed rest and which will provide obstetrical aid, increases in proportion to the increase in the industrial employment of married women. Industrial employment of nxothers too frequently means em- ployment with unabated energy until close to the day of birth and an early return thereafter to the detriment of both mother and child. The explanation is simple; the family cannot afford to lose the mother's contribution to its exchequer. In some countries the need of rest was seen even before the cause of its absence was understood. This led, as in our own country, to legislation prohibiting the industrial employ- ment of mothers for specified periods before and after childbirth. In this form the prohibition only increases the financial stress upon the family. The economic strain could be eased by a provision for medical aid or a substitute for loss of wages or both, thereby making it financially possible for the mother to take the necessary rest. The public interest in mlaking such provision has developed three forms of state assistance: (i) maternity insurance through state sub- sidized voluntary systems of sickness insurance, (2) maternity insurance through obligatory health insurance systems and (3) assistance given entirely at public expense. The assistance takes two forms, — obstet- rical aid and cash payment. The state provision has been in addition to lying-in hospitals, nursing attendance and schools for mothers which warm-hearted individuals in all countries have provided. Maternity insurance on a voluntary basis, it should be realized at the outset, is almost non-existant. The only persons wishing this form of insurance are those who will become mothers. In practice maternity insurance has been provided as one feature of a sickness insurance plan. But even on this basis, its development has been meager. STATE ASSISTED VOLUNTARY INSURANCE The modem movement for assisted insurance appeared in France in 1891 when the Mutualite Maternelle was founded in Paris. This organization, duplicates of which rapidly appeared in the provinces, furnished a confinement benefit of 48 francs ($8.36) and a nursing benefit of 10 francs ($1.93) in return for an annual contribution of 3 francs ($.58) from the insured. Although nominally mutual insurance, (185) i86 a large part of the income of the Maternelle is derived from state and municipal subsidies and donations from philanthropic individuals. In the same year, Sweden passed a law authorizing a state subsidy to mutual sick funds meeting governmental standards required for recognition. These societies in 1910 insured 500,000 persons or not quite 10 per cent of the population. The act of 1912 made special efforts to stimulate the recognized societies to grant maternity aid by providing a state subsidy of two-thirds the minimum benefit. The min- imum maternity benefit was placed at 90 ore ($.24) a day payable for at least two weeks or hospital treatment as an alternative. The state sub- sidy is 60 ore ($.16) per benefit day for a maximum benefit of 4 kronor ($1.07) a day payable for not more than forty-two days. Benefit is granted only so long as the mother abstains from employment. The Danish law of 1892 provides a state subsidy and state super- vision to recognized societies providing home or hospital care, medical and obstetrical aid. In practice pecuniary aid during sickness and a minimum maternity benefit of one krona ($.268) a day, granted after a ten months' waiting period, are also furnished. The membership is com- posed almost equally of men and women and in 1914 included approx- imately 30 per cent of the Danish population. Two years later Belgium passed a law which carried with it a gov- ernment subsidy to recognized mlutual aid funds furnishing temporary aid to members and their families in case of accident, sickness, inva- lidity, or childbirth. In 191 1 Switzerland followed with a law providing governmental subsidies to societies furnishing benefits in time of sickness. Although insurance is voluntary, the law provides that cantons and communes may make insurance compulsory. The maternity provision, the law stip- jlates, shall be paid only after a waiting period of nine months and shall consist of a minimum of one franc ($.193) a day for at least six weeks and of an additional benefit of at least 20 francs ($3.86) as a nursing benefit during the following four weeks, provided that the mother nurses her baby during this period. Medical aid and medicines may be furnished either as a substitute for the cash benefit or in addi- tion to it, according to the rules of the individual fund. The federal government contributes 20 francs ($3.86) toward the maternity benefit and the entire 20 francs ($3.86) for the nursing benefit. The provision of maternity care through a state assisted system of voluntary insurance is confined to those countries which have developed this method of handling sickness insurance. OBLIGATORY INSURANCE Nations which have enacted obligatory systems of health insurance universally include maternity care as part of the sickness provision. i87 Although the more comprehensive systems have sometimes found it possible, as in Great Britain, to provide not only for insured women but also for wives of insured workers, their primary concern is with the wage-earning mother. The earliest provision of maternity care through legislation for compulsory health insurance wasi that of the German act of 1883. This legislation, as it was subsequently amended and recodified, applies to all manual employees and other specified groups of employees earning less than $595 a year. These persons of whom approximately 4,000,000 are women and who total something over 14,000,000 or 20 per cent of the entire population, are automatically insured in the appropriate fund — the local, the rural, the establishment, or the guild fund. The insured persons pay two-thirds of the cost, the employer one-third and the government the expense of central supervision. In addition to medical care and cash benefit furnished during sickness and funeral benefit at death, the funds furnish insured women who have been members for six months with a maternity benefit for two weeks pre- vious and for six weeks following confinement. The benefit is one- half the basic wage but may be increased. Some variations are pos- sible: iti rural funds the duration of benefit may vary from four to six weeks ; with the consent of the mother, institutional or home nursing care may be given, thereby reducing the cash payment by half. Ben- efits may also be granted the uninsured wives of insured workers. The act is especially generous in permitting more extended care : medical and obstetrical care by midwives or physicians may be furnished ; med- ical care for the disorders which may accompany pregnancy may be given ; a pregnancy benefit equal to one^half the basic wage may be paid for not more than six weeks in case of disability; a nursing benefit equal to one-fourth the basic wage may be paid for a maximum of twelve weeks following the confinement to any mother nursing her child. The money expended in 1912 for cash maternity and pregnancy benefits totaled $1,715,038 or 1,5 per cent of the total expenses of the health insurance system. Under the stress of war, some of the extensions beyond the re- quired minimum of six weeks' maternity benefit have been curtailed. In their place there has been established for the duration of the war an extensive system of maternity grants paid for largely by the state but administered by the insurance funds. This benefit consists of: (i) a lump sum payment of 25 marks ($5-95) to defray the expenses of confinement; (2) a daily allowance of one mark ($.238) (including Sundays and holidays) for two weeks before and six weeks following confinement; (3) a grant of 10 marks ($2.38) to pay doctor's or mid- wife's fee should their services be necessary for pregnancy disorders; and (4) a nursing benefit of .50 marks ($.119) a day payable for a maximum of twelve weeks. This benefit is payable to: (i) women 1 88 whose husbands render war service and were insured; (2) women whose husbands are or were until the beginning of the war in the mer- cantile marine, and whose annual remuneration does not exceed 2,500 marks ($595) ; (3) to women whose husbands render war service and who are of "small means"; and (4) on behalf of an illegitimate child of a participator in the war. If the women themselves are insured it is stipulated that the funds bear the cost ; if women of the third and fourth groups are emiployed but not insured, it is provided that the employer is liable; if they are not insured or employed it is provided that the state bear the expense for the first group, and that the marine trade association is liable for the second. Austria in 1888 enacted a measure for compulsory sickness insur- ance which included provision for maternity care. Included within the scope of the act are workmen and administrative officials, a total of over 3,694,000, of whom nearly a fourth are women. The cost is borne two-thirds by the worker and one-third by the employer. To women who have been members for six months a maternity benefit of one and a half times the basic wage is paid for four weeks. In addition med- ical and obstetrical aid, medicines and therapeutic measures are sup- plied. Under this system cash and mlatemity benefits are paid annually for approximately S5,ooo cases of childbirth. Hungary in 1891 introduced a comprehensive sickness insurance system, obligatory for all workers in industry, trade or commerce with incomes of less than 2,400 crowns ($487.20) except in so far as it is voluntary for special groups such as home workers, farm laborers, etc. The cost is borne one-half by the employee and one-half by the em- ployer. The maternity provision consists of cash payment for six weeks equal in amount to the regular sick" benefit. The amount, however, may be increased by the society and the period may be extended to eight weeks. In addition, free medical and obstetrical aid is furnished not only to the insured women members but also to the dependents of insured members. The Grand Duchy of Luxemburg in 1901 passed an act providing maternity insurance as one feature of a compulsory sickness insurance system which embraces workers in a comprehensive list of occupations earning less than 3,000 francs ($579) a year; To qualify for maternity benefit members must be insured for at least six months. Benefit con- sists of cash payments equal to the regular sick benefit for a least four weeks. The duration may be increased to six weeks and the benefit may be extended to the uninsured wives of insured men. Norway in 1909 enacted its long discussed plan for obligatory sick- ness insurance. Insurance is compulsory for all workers and salaried employees with incomes of less than 1,400 ($375) and 1,200 kronor ($321) respectively for city and rural workers. To those who meet the requirement of ten months' insurance, a cash maternity benefit i89 equal to 60 per cent of the basic wage is paid for six weeks and! medical care is provided if necessary. The cost O'f the sickness insurance system is distributed as follows : to the worker six-tenths, to the employer one- tenth, to the state two-tenths and to the commune one-tenth. In 1910 Servia followed with a compulsory sickness insurance law providing a maternity beneiat for the six weeks before and the six weeks following confinement. Included within the scope of the act are commercial and industrial workers. The expense is shared equally by employee and worker; to this the state also contributes. Maternity benefit consists of both medical care and cash benefit of at least 50 per cent of wages. Provision is also made for the uninsured wives of insured men. In 191 1 Great Britain enacted its famous national health insurance act covering all manual workers and others earning less than $768.64 a year, a total of thirteen and a half million persons or nearly 30 per cent of the total population. Of this number over four million are women. In the case of women the cost is borne three-eighths by the employer, three-eighths by the worker and one-fourth by the state. In addition to medical and cash benefits payable during sickness the act provides, both for insured women and the wives of insured men, a maternity benefit of 30J. ($7.30), exclusive of all medical care. By the amending act of 1918 the waiting period for their benefit is increased from twenty-six to forty-two weeks. It is estimated that during the first year of operation, 1913, 887,000 mothers received maternity benefit involving a total expenditure of $7,000,000. ■ The act also entitles women who cease to be insured within a year after their marriage to a maternity benefit at the birth of the first child born within two years of marriage. Scarcely was the act in operation, when a movement was started to enlarge the public provision for maternity by substituting for the cash maternity benefits of the act a system of national maternity care. This, it was' proposed, should provide every mother (regardless of her own or her husband's insurance) with medical care during pregnancy and at childbirth. The stimulus given by the war to the conservation of in- fant life has led the local government board to promise to local author- ities financial assistance in paying the salaries of midwives, nurses and others engaged in maternity and infant welfare work. Russia included provision for maternity care in its compulsory sickness insurance law of 1912. It provides for those, who have been insured for three months before confinement, a cash benefit varying from one-half to full wages and payable for two weeks before and six weeks following childbirth. The cost of this and the other cash ben- efits is met by the worker and employer, the employer's share being two- thirds that of the worker. In addition midwifery assistance for em- ployees of factories and mines is provided at the expense of the employer. I9<3 In the same year Roumania enacted a compulsory health insurance law applicable to specified groups of workers. Women with twenty-six weekly contributions to their credit are entitled to a cash maternity benefit payable for six weeks. Where the mother nurses her child a nursing benefit is granted for six weeks. Where financial resources permit, the funds may during six weeks provide medical and obstetrical aid for the uninsured wives of their members. Unlike other systems of health insurance, the employee bears the entire expense. The following year the Netherlands passed an obligatory health insurance law covering workers earning less than specified sums. In pregnancy cases, payment is made on the first day of incapacity and is paid throughout the period of disability. The benefit is at the rate of 50 to 90 per cent of the average daily wage. A miscarriage (confinement) benefit equal to full wages is paid during the entire period of incapacity. A woman is disqualified fronn receiving benefit if pregnancy antedates the commencement of the insurance. The cost of the system is shared equally by employers and workers. In 1910 Italy introduced a law which is unique, a system of ob- ligatory maternity insurance as a unit and not as a part of a health insurance system. The law applies to women industrial workers be- tween fifteen and fifty years of age.. To the equal contribution of employer and worker the state contributes a subsidy of one-fourth the confinement benefit of 40 lira ($7.72) and pays in addition administra-' tion expenses. The maternity provision made by systems of obligatory health in- surance are preeminently for the wage-earning mother. A cash benefit is given to compensate, as for other causes of disability, for wages lost because of incapacity for work. Medical care is less frequently given. Three acts, those of Great Britain, Hungary and Serbia, extend mater- nity benefits to the wives of insured workmen, while others, notably the German, make this permissive. For this benefit the insured workers contribute an amount at least equal to the employer's share, while the state subsidizes in varying proportions. Maternity care furnished wage- earning mothers on this basis should not be confused with schemes for the endowment of motherhood. PENSIONS TO MOTHERS Australia is the first state to provide financial assistance to mothers in confinement without requiring any direct payment for this. The Australian act of 1912, the only one of the kind, provides for a grant of £5 ($24.30) to every woman inhabitant of Australia upon the birth of a living child. The figures for 1916 show that the grant was paid for births equivalent to 100 per cent of the births registered in that year and that the total expenditure was $3,206,000. 191 French legislation of 1913 prohibits the industrial employment of women during the first four weeks after childbirth. During this period it provides aid from public funds, but restricts the grant tO' women of French nationality employed by others for wages. The grant is limited to a maximum of eight weeks of which four must follow confinement and is given upon condition that the mother give up her usual occupation, that she take all practicable rest and that she follow health instructions given her. Before a grant is made the applicant must submit a state- ment showing, among other things, the family expenses and the family resources available while the applicant takes the rest. The daily allow- ance, varying from .50 francs ($0'.096) to 1.50 francs ($0,289), is decreed for each commune by the municipal council. An extra allot- ment of .50 francs ($0,096) a day is given if the mother nurses the child. The intent of this provision is obviously much the same as that of Danish legislation for the same year which provides that any public relief given lying-in women during the four weeks following confine- ment when their industrial employment is prohibited, shall not be re- garded as poor relief. Swmmary. The aim of existing European legislation for maternity insurance is to provide primarily for the peculiarly urgent needs of wage-earning mothers at their confinement. Provision is commonly made as a part of a sickness insurance system. The greater prevalence of compulsory systems makes this the dominating method. In every instance cash benefit is furnished, usually equal to the sick benefit and payable for four to eight weeks; this is sometimes extended by special pregnancy and nursing benefits. In addition medicaland obstetrical aid are fre- quently provided. Benefit is granted only after a long waiting period usually greater than that required for receipt of other benefits. The same ends are achieved in Italy by a compulsory maternity insurance and in France by grants from public funds to wage-earning mothers. Australia is the pioneer in providing universal aid to all mothers. Both Germany and Great Britain under the stress of war emergency have extended public assistance to lying-in women beyond the original scope of the insurance system. CHAPTER XIII MINORITY REPORTS ON HEALTH INSURANCE MINORITY REPORT ON HEALTH INSURANCE Robert E. Lee. Accepting appointment on this Commission as an opportunity for a service in a field of great possibilities for good, and entering upon my duties with an open mind and unbiased judgment, makes it regret- able to be unable to subscribe to the report submitted by a bare majority of the Commission on that portion of its report regarding "Compulsory Health Insurance". Health Conservation and Sickness Prevention I gladly joined with all members of the Commission in recom- mending reform in the matters coming under this head. The most potent means of insuring health, it seems to me, is the elimination of conditions which produce sickness, prevention of the spread of infec- tions, timely use of corrective medicine and surgery, etc., and not through relieving persons of the liabilities resulting from wrong living, abuse of the laws of nature and hygiene, and placing a premium upon malingering, dissipation and wilful abuse. Old Age Pensions In the recommendation of the Commission regarding old age pen- sions I am in full accord, believing that some practical method should be adopted to provide, under equitable regulations, for those who reach the ages when they are unable to provide for themselves. Compulsory Health Insurance I cannot subscribe to the declaration of principles made by the majority on this subject, feeling that the researches of the Commission or the information available to its membership, did not furnish coti- vincing data to warrant their recommendation upon a subject which is practically new in this country, and upon which there has been no suc- cessful experience anywhere that proves that compulsory health insur- ance either reduces the amount of sickness or prevents it. My position is in no spirit of obstruction and no position of antag- onism to the majority in the development of social ideas, but, in justice (192) 193 to myself as well as them, I will outline my reasons for opposing their recommendation upon this subject. There has been no general demand from the people of Ohio for the enactment of legislation upon the subject, and such demand as there is in evidence comes purely from the voluntary explorers of unknown, uncharted sociological ideas. Proof of this statement is the small at- tendance and lack of general interest manifested in the public hearings held by the Commission. Disavowing any intention to be discourteous or offensive in my criticism, it has seemed to me that the chief effort of the chief investigator of the Commission was to gather data to sup- port a preconceived theory . rather than to show whether compulsory health insurance would reduce sickness, and, if so, suggest a practical method of its application. The majority report states that, "The principle of health insurance is approved as a means of distributing the cost of sickness." Certainly there is no insurance of health in a scheme to distribute the cost of sickness. The majority report also says that: Health insurance should be required for all employees to be paid for by employees and employers in equal proportion, the state should pay all costs of state administration. Is it not pertinent to ask what has employment to do with the question? Is sickness known only to the employed? If the desire is to distribute the cost of sickness by taking the burden from the indi- vidual, why impose it upon employee and employer; why not upon society as a whole in proportion to their ability to pay, and where every citizen may be a beneficiary, with reference only to his needs and not with reference to his employment? Is the explanation that funds can be obtained more easily from these sources, and that in turn employers can distribute it through additions to the cost of production? The majority proposes to apply the insurance as follows : I. Payment of part wages to workers disabled by sickness. II. Complete medical care for workers, including hospital and home care and the cost of all medicines and appliances. III. Adequate provision for rehabilitation, both physical and voca- tional, in cooperation with existing public departments and institutions. IV. Dental care. V. Medical care for the wives, children and dependents of the workers and a burial benefit for the worker. This section certainly involves a gigantic stride in the direction of German state socialism, — provision without stint or limit for extensive and expensive medical, surgical and dental care for the worker and all 13 194 dependents at the judgment of a medical board and at the expense, in equal proportion, of the employer and his fellow workers. The other sections of the report deal with details generally, but jseem to be included more with the view of insuring the payment of rnedical and hospital charges rather than for the conservation of health. Discussing briefly the cost, should the General Assembly enact legislation conforming to the recommendation of the majority report, it has been estimated it would require from $30,000,000 to $80,000,000 per annum. The wide variance in these estimates indicates a decided lack of knowledge upon the subject. Furthermore, who will provide the funds for the expansion of hospital facilities, essential to the successful : ;Operation of the scheme, it being estimated that this item would require from $200,000,000 to $500,000,000? It may be of some service to quote extracts from reports of recog- nized experts who have studied the operation of compulsory health insurance in Germany and Great Britain. The following is an extract from an article published by Wm. A. Brend, M. A., M. D., B. Sc:, of England, in his analysis of the national insurance act of England. The Insurance Act a Public Health Measure. The national insurance act is the most ambitious piece of public health legislation ever carried through in this country. No previous measure has directly affected so large a number of persons, involved so great a cost, made such demands upon administration, or been introduced with such lavish promises of benefit to follow;, and no previous measure has ever failed so signally in its primary object. Again he says in speaking of the report of the royal commission on the poor laws : Both the majority and minority reports called attention to the association of poverty with sickness, but neither recommended national insurance as a remedy, nor took the view that poverty was the main cause of ill health. The most prominent claim made by the advocates of compulsory health insurance is that it will reduce the amount of sickness; yet the official German report, the 24th annual report, shows the reverse is true. The following is an extract from the report: During the period covered by this fund the number of days of sickness per 100 persons increased from 5.68 days each in 1887 to 7.75 days each in 1905 for males, and 5.19 days each to 8.21 days each for females, or an increase of 36 per cent for males and 58 per cent for females. No evidence is here to substantiate the claim that sickness will be reduced by compulsory health insurance. The following is an extract from a report of Frederick L. Hoffman, of Newark, N. J., recognized as one of the leading statisticians of America ; 195 The sickness rate among German wage-earners has not been reduced, but remains at a figure far above any corresponding conditions of ill health disclosed by impartial investigations in this country. In many of the funds more than half of the wage-earners will claim sickness and medical benefits throughout the year. Most of these benefits are, by independent inquiries, proven to be unjustifiable demands upon the funds, practically insisted upon as a right either as unemploy- ment benefits or poor relief disguised as claims for sickness and inability to work. The following is an extract from report of special committee ap- pointed by the National Civic Federation, the committee consisting of: J. W. Sullivan, Chairman, Representing Wage-earners. Arthur Williams, Representing Employers. P. Tecumseh Sherman, Social Insurance Specialist. Referring to compulsory health insurance they say regarding the system in Great Britain: What the state insured wage-earner pays for his insurance is not summed up in his weekly stamp costs alone. He takes on burdens aside from the financial. His relations with the public authorities, his employer, his benefit society, his doctor, and the weaker members of society have all been changed. If healthy, sober, thrifty, and a skillful artisan, he has paid a high price in the loss of various personal rights, of the rights to be free of police interference when selecting his own methods of thrift, of the right of preventing an employer from making deductions from his wages, of the right of being in a sick benefit society having liberty of self-management, of the right of an unrestricted selection of a doctor, and of the undoubted right not to be saddled with an unfair share in the support of the mass of chronically sick, or sham sick, or self-deceived as to sick- ness, and other such known burdens of society in the helpless classes who would forever be ''on the benefits." Summarized, my objections are as follows : I. The compulsory feature is wrong in principle for it would mean the sacrifice of the independence of a large number of people. II. The proposed distribution of costs does not equitably place the burden upon society as a whole. III. Before adopting questionable experiments all possible re- sources should be utilized to prevent sickness. IV. To place upon society as a whole, the responsibility for indi- vidual failure would bring us dangerously close to policies which are at present of the gravest concern to the entire civiHzed world. In view of the conditions suggested, supported by data contained in this report, it is respectfully recommended that the General Assembly take the necessary steps to make more efifective the health supervising 196 machinery of the state and to secure health conservation by adopting sickness prevention measures. Take no action to enact compulsory health insurance legislation until it can be reasonably proven of value. Finally, aside from all arguments, how far are the General As- sembly and the people of Ohio disposed to go in substituting state socialism for individual liberty, in changing from a government, owned and directed by the citizenship, to a citizenship owned and directed by Respectfully submitted, Robert E. Lee. MINORITY REPORT UPON SUBJECT OF HEALTH INSURANCE Thomas J. Donnelly O. B. Chapman. We cannot agree that the state should at this time enact compulsory health insurance laws, dividing the cost of such insurance equally be- tween the employer and employee, with the state paying the cost of administration. We do not believe that the employees should be de- clared indigents or wards of the state because they should have been the victims of social injustice, and because of the failure of the state to perform its full health duty; or that they should, like Esau, be con- fronted with the proposition to sell their birthright for temporary, and, under the proposed health insurance plan, partial relief. This birth- right, in this instance; is individual and industrial Hberty. For its sur- render, it is proposed to compel all employers to contribute to funds in equal proportions, "democratically administered," and the plan super- vised and administered by the state. Inasmuch as the wages, hours and working conditions of employees determine the housing, food and health of the employees and their fam- ilies, if a compulsory health insurance plan is put into effect, justice would dictate at least that, where the wage is below the standard re- quired to maintain the employee and the average sized family in com- fort and health, industry should bear the whole cost of health insurance and that the same should be collected, administered and disbursed by the state. But, after all is said, the advocates of present plans for health insurance fail to recognize that moneys levied upon employers to pay for sickness of employees will divide the two into classes of givers and receivers, and the tendency and result, we believe, will be to cause a demand to be made upon the part of the giver class to be granted the right to regulate and supervise the class receiving the direct money benefits. We do not believe that such funds can be "democratically adminis- tered" where the employer gives and the employee, although contribut- ing, is the apparent recipient of benefits at the expense of the employer. 197 It is our opinion that the state should be slow to curtail the liberties of the individual, and should only then do so when failure to act im- perils the interests of the whole or any considerable part of the people. Above all, no legislation should be considered which will have a ten- dency or invite an attempt by one class of the citizens to impose their will upon the others. Under the proposed compulsory health insurance we believe there would be promoted such effort to impose the will of one class upon the other under the plea that they were paying part of the cost of the sickness of the other class. Industrial feudalism and supervisory government are the two greatest dangers to American freedom, equality and the development of character and responsibility of the individual. It is our firm conviction that the plan of health insurance as outlined and proposed by the ma- jority members of the Commission contains within it the germ of in- dustrial feudalism, that it will destroy the independence of the workers and retard the development of character and responsibility by the American wage-earner and naturalized industrial employees. The proposal of the advocates of compulsory health insurance to have the state spend $500,000 in supervising and administering the plan is sufficient proof that it is proposed to have the state, in conjunction with the contributing employers, supervise and administer the employees inj their private and personal affairs, imder license of law and under the plea that it is for the common good. One of these dissenters proposed, and both voted to approve, the principle of health insurance for the purpose of meeting the cost of sickness. The approval of the principle should by no means obligate one to the surrender of his liberties. Opportunity should be given the citizens to study the principle to the point of practice, and the state oould wisely use the $500,000, which the advocates of the compulsory plan agree would be the probable cost to the state of supervising and administering the plan, in promoting the public health through proper preventive measures and looking to the curtailment of tuberculosis, typhoid, smallpox and venereal diseases. An adequate public health department could educate the public, improve factory and housing con- ditions, abolish slums, improve rural health and promote the organiza- tion of health insurance units, and the state could encourage the same by the offer of subsidies, if organized upon a plan approved by the state. This would leave the initiative with the insured and allow them to determine the form and scope of the insurance and the extent to which they desire to be supervised. It has been stated repeatedly by the advocates of compulsory health insurance that the employees cannot carry the cost even undei an insurance plan, and that it is therefore necessary .to compel employers to contribute to the funds to be created, with the state paying the cost 198 of supervision and administration. If this is true, it surely finds labor in a deplorable condition, especially when it is taken into consideration that the payment of 50 cents per week by all employees, with employers not contributing and state supervision and administration excluded, would bring about the! idealic health conditions dreamed of by the advo- cates of compulsory health insurance This is an indictment of Amer- ican industry, if true, which it shotdd not be permitted to escape by the payment of 24 cents per week per employee, and thereby licensed to continue the condition. Finally, interference with the rights of the individual and compul- sion should be the last resort of free government and not the first. PART III: OLD AGE AND OLD AGE PENSIONS CHAPTER XIV PRESENT METHODS OF CARE OF THE AGED Dr. John O'Grady The Commission decided that an investigation be made' to deter- mine the present status of the care of the aged in Ohio. In accordance therewith the following specific studies were made. I. A study of the problem of old employees in industry to deter- mine to what extent changes in industry are supplanting older employees. II. A study of county infirmaries to determine the present status of public care of the aged. (Forty-five infirmaries were inspected.) III. A study of private old folks' homes to learn the extent and methods of care. (Twenty-eight homes were inspected.) IV. A field survey of representative urban districts to learn the economic status of the aged people in their own homes. These studies constituting the next fivei chapters of this report were made by Rev. Dr. John O'Grady of the Catholic University of America, Washington, D. C, to whom the Commission is especially indebted. THE OLD AGE PROBLEM Dr. John O'Grady Very few wage-earners expect to be able to work until the end of their lives. They ordinarily look forward to a few years before death when they will no longer be able to earn wages. How are they to obtain a livelihod during those last years of Hfe? This is the problem of old age as it affects the working-man. The business or professional man is also facing a problem of old age. He is exposed to certain risks, such as business failure and long periods of sickness which may leave him without the means of support during his last days, but he is better prepared to insure against these risks than the average wage-earner. For the adult, the prospects of living to old age are good. Accord- ing to the American experience of mortality, of every loo persons alive at 20, 64 will reach the age of 60 ; 54, the age of 65 ; and 42, the age of 70. The person who has reached the age of 65 may expect to live II years, and at 70 he may expect an additional, nine years of life,^ -'United States Bureau of the Census, United States Life Tables, 1910, pp. 16, 17. (201) 202 If, therefore, the working man is compelled to retire at 65, he will require from $1,500 to $2,200 to maintain himself for an existence mini- mum during the remaining years of his life. In order to maintain him- self in comfort and decency and to supply the wants incident to old age, he will require at least twice this amount. Old age, as it affects the wage-earner, has two important aspects. First, there is the question of how long he may expect to work, or to put the matter in another way, at what age he will be relegated to the industrial scrap pile, and secondly, there is the question of how far he may be able to provide for the closing years of life when he will no longer be able to work. The length of the working life is of vital importance in the old age problem. If the wage-earner is superannuated at 65, the difficulty of maintaining himself and his dependents, if he should have any, is a seri- ous one, but if he is superannuated at 55 or 50, it is much more serious. During the past few years much has been said and written about the influence of high power machinery and the speed of the modern factory on the length of man's working life. Many writers have in- clined to the view that the economic usefulness of the wage-earner in a fairly large number of occupations comes to an end at 50 or at best, at 55- No attempt on a large scale has been made in the United States to show the relation between occupations and the length of the working life. Professor Todd, of the University of Minnesota, has given an interesting statistical sumimary of the census data on the number of persons gainfully employed, and has drawn interesting conclusions in regard to the problem of superannuation. He, however, has made no attempt to discuss the significance of the age distribution of persons engaged in different occupations. Nor is there any authoritive in- formation on the second question which confronts the student of super- annuation, namely, the extent to which wage-earners in this country have provided for old age. Massachusetts has made two studies of old age dependency, but they are confined almost exclusively to almshouse paupers and to recipients of outdoor relief. These persons cannot be overlooked in any comprehensive study of old age dependency because the state is naturally interested in removing or neutralizing the causes of pauperism and in giving its institutional wards the kind of treatment best suited to their condition. But in connection with old age pension proposals, the almshouse poor and the recipients of out door relief are a negligible factor. Wage-earners do not, as a rule, seek an asylum in their last days in almshouses or county infirmaries. They will make any sacrifice rather' than incur the stigma of pauperism attached to these institutions. Wage-earners, without friends or money in their old age. would miuch prefer a private institution for the aged to a county in- 203 firmary or almshouse, but even the private old folks' home they look upon as a last resort. There are two plans, either one or both of which may be followed in studying the conditions of the aged wage-earner. First, the length of the working life in various occupations may be studied. If it is discovered that the workers leave a certain occupation at 50 or 55, one should find out what becomes of them and what were the precise hazards of the occupation which they left. The second plan is to make a house- to-house study in one or more typical industrial centers. It was thought that the second plan would give the Commission a better general picture of the occupational career, present physical condition, domestic relations, savings and dependency of aged wage-earners. It was decided, there- fore, to make two surveys in typical industrial centers in the state. A section of the city of Hamilton and a section in Cincinnati were selected. The institutional poor, whether in county infirmaries or private old folks' homes, were not overlooked in the study of old age dependency in Ohio. The public is interested in the types of persons in these insti- tutions, as well as the care which they receive. Chapters XVII and XVIII are devoted to a study of these institutions. The aged assisted by private philanthropy, preliminary investigation showed, were referred as soon as possible to institutions. Since this group did not differ materially from the aged institutions, the investigation was not car- ried further. As a preliminary to field investigations, an analysis of the figures of the 1900 and 1910 census on the age distribution of persons employed in the different occupations was considered necessary. Chapter XV is devoted to this analysis. CHAPTER XV THE OLD MAN IN INDUSTRY: AN ANALYSIS OF CENSUS DATA Dr. John O'Grady The census of 1900 distributes the gainfully employed into nine age groups, as follows: 10 to 15, 16 to 20, 21 to 24, 25 to 34, 35 to 44, 45 to 54, 55 to 64 and 65 and over. This census not only indicates how many workers were employed at the different age groups, but also speci- fies the occupations in which they were engaged. It is, therefore, pos- sible to obtain from the census of 1900 the age distribution of workers in different occupations. The census of 1910 is not so satisfactory in this regard. Instead of nine age groups, the 1910 census distributes the gainfully employed into five age groups; 10 to 13, 14 to 15, 16 to 20, 21 to 44 and 45 and over. To the student who is anxious to discover how far the old man is being retained in industry, the census of 1910 gives little aid. He is, therefore, compelled to go back to 1900 for the information which he is seeking. Even if the student tries to compare the gainfully employed 45 and over at the two enumerations he encounters other difficulties. In 1900, the gainfully employed of various ages were classified according to oc- cupation. In 1910, the classification of occupation by age groups was primarily industrial, with sub-classifications according to occupation. The actual content of individual groups has been changed. For ex- ample, in 1900, helpers and apprentices are included under the trade in which they were occupied, but in 1910 they are given as a separate group. Certain types of industry have been subdivided and redis- tributed so that comparable groupings cannot be established. The at- tempt was made in 1910, in contrast to previous years, to determine as specifically as possible the character of service rendered, or the kind of work done, rather than the article made or worked upon or the place where the work was done. While the different system' of classification adopted by the census of 1910 makes comparison of its figures with those of 1900 very difficult, and while its age classification is anything but satisfactory from the standpoint of the student of superannuation, its more minute classification of occupations is helpful. It gives a rather definite idea of the kind of work in which persons less than 45 and 45 (204) 205 and over are engaged. Had the age classification been extended to 55 or 65, invaluable results would have been attained. Table I shows for the United States and for Ohio the proportion of men 45 years of age or over gainfully employed. The data are pre- sented for these age groups in cumulative form. The figures for both 1890 and 1900 show a decrease in the number of males employed at each succeeding age period after 45, and also show that in each succeeding decade the percentage of males employed at these ages tends to become smaller. Approximately 85 per cent of the males 55 and over in the United States were employed in 1890, as compared with 80.7 per cent in 1900; 73.8 per cent of those 65 and over were employed in 1890, as compared with 684 per cent in 1900. The figures for Ohio during the same periods are equally significant. Eighty and eight-tenths per cent of the males 55 and over in Ohio, were em- ployed in 1890, as compared with 76.8 per cent in 1900, and 69.0 per cent of the males 65 and over in the state were employed in 1890, as compared with 63.6 per cent in 1900. We have no means of knowing exactly how many persons 55 and over and 65 and over were employed in the United States in 1910,^ but the census figures show a decrease in the proportion of persons 45 and over gainfully employed that year as compared with 1890 and 1900.* If we assume the same rate of de- crease between 1900 and 1910 in the percentage of males 55 and over employed as that which took place between 1890 and 1900, 76.8 per cent of the males 55 and over in the United States were employed in 1910, and 72.8 per cent of those over the same age in Ohio. Making the same assumption in regard to those 65 and over, 63.0 per cent of the males in the United States were employed in 1910, and 58.2 per cent in Ohio. It may be assumed then, that of the 4,660,379 males 55 years of age and over in the United States in 1910,8 3,579,171 were gainfully employed; of the 290,266 males of the same age in Ohio,' 211,313 were gainfully employed; of the 1,985,976 males 65 and over in the United States,' 1,251,165 were gainfully employed; and of the 129,598 aged 65 and over in Ohio in 1910,' 75,426 were gainfully em- ployed. ' Thirteenth Census of the United States, "Occupation Statistics," 1910 Table 30, p. 71. ' Twelfth Census of the United States, "Occupations," 1900, Table XXXVIII, p. CXVII. ° Thir^teenth Census of the United States, 1910, "Population," Table 32 d 318 'Ibid., Table 43, p. 394. • f- ■ 206 o Co to ttJ! ■2-e i s ■S o (J o Oh s ^ a hi •a c ,6 CM e OJ ■2-° H 3 c -> O O, H OJ > o T3 c C c« d o p-( n a o iO CD "3 OOGOi-H OS CO CO r-( i-H t- CO lOOO C^ lOOi OCr-'-H 1—1 CO t- (M CM t- -^ 05 iO CMCMOj Ol -^ [>. (O 00 CO CO 1—1 CO 00 CO CO 05COCO CO 03 Oi 03 C<1 iO i; CDOOO i-H COCO 00 (35 CD t- COCM 00 CM 00 (NOOOi CO lOlO CM »0 CO OOCO i-H lO "^ CO OO Oi '— I lO t- 1— ( 1— I T-H (M Ci CO CD CM "^ <:o '-|-^ CO xJH COCO"^ ■^ b- l> Oi coco cooa-^ CO C3S O '— I QOo:ici XJ U CM « - ;§ ID o:: !;; »^-^ 0= CO ■ ■ ri f--^ aj mo" " ^Oil-H - .S oG-2 MH.'JJ rt -4-1 a. SH g, ■" O " HtSSo o --ij ^ Op ^- a a '-5 Co C ^ rt Co O fSSv nj ^ ^' -'5 == 207 Both the census of 1890 and that of 1900 show otnly a small per ■ cent of women 65 and over gainfully employed. Only 9.1 per cent of the women 65 and over in the United States were employed in 190O, and 8.3 per cent in 1890. The American woman customarily does not continue in a gainful occupation after marriage. Those who remain in industry after 55 represent to a very considerable extent the unmar- ried remnant. The married woman depends on her husband for main- tenance, but if the husband should die and leave her without property' or income, she is frequently faced with the alternative of returning to work or becoming dependent. If the husband should die after she has reached the age of 50 or 55, it will be very difficult, if not impossible, for her to secure work. Some women over 55 fry to earn their liveli- hood by taking -in laundry or dressmaking, but this becomes increasingly difficult after 60. The condition of the propertyless old woman is, there- fore, much worse than that of the old man. The latter, except when broken in health or permanently disabled, can generally secure some kind of employment. Since the percentage of women 65 and over employed in the United States in 1900 represented only a very slight increase over 1890, we may assume for practical purposes, that the percentage over the same age employed in 1910 was the same as in 1900. On this assumption, 178,683 or 9.1 per cent of the 1,963,548 women 65 and over in the United States in 1910,'' were engaged in gainful occupations; and 9,387, or 7.1 per cent of the 132,212 women 65 and over in Ohio' in 1910^ were gainfully employed. , - : While her husband lives and is able to work, the condition of the' married woman is fairly secure. Of the 132,212 women 65 and over in Ohio in 1910, 46,968, or approximately 35.5 per cent, were married.' The chances are that since 58.2 per cent of the men 65 and over were gainfully employed, at least half of the married women 65 and over had husbands who were able to maintain them. If to these we add the 9,387 who were employed, we get a total of 32,871 wom'en 65 and over in Ohio provided for either by their own labor or by their husbands'. It may be presumed, therefore, with a fair degree of accuracy that there were 54,172 males 65 and over in Ohio, in 1910, who were not engaged in gainful occupations, and 98,341 women who were unoccupied or whose husbands were unoccupied. The student of superannuation is interested in the relation of oc- cupation to the length of the working life. For a number of years past it has been claimed that the man over 45 is not desired in the modern shop, and the policy adopted by many employers of labor in this country would seem to substantiate the claim. We know from practical ex- ' Thirteenth Census of the United States, 1910, "Population," Table 32, p. 320. 'Ibid., Table 43, p. 394. 'lUd., p. 564. 208 perience that advancing years and grey hairs are by no means a dis- j advantage in all occupations. In business or professional life most men, do not attain prominence much before 50. It is safe to say that 90 per cent of the great leaders in the business and political affairs of th^ nation are men past 50. In certain highly skilled trades a man of 60 is just as valuable as a man of 40, and even at 65 his skill, directive ability and steadiness may enable him to compete successfully with a younger man. The farm owner can still continue to do good work in a managerial capacity after 65. While the age of 60 or 65. may be no disadvantage to men in execu- tive and managerial positions, or positions in general requiring the ex- ercise of brain power, we know from general observation that very few men of 60 or even of 55 are employed in large numbers in occupa- tions involving manual labor. In order to determine to what extent this general observation accords with existing statistical data on the age distribution in different occupations, a study of the 1900 census was made. In studying the 1900 census the percentage of the total number of gainfully employed workers in all occupations combined coming within the age groups 45 to 54, 55 to 64 and 65 and over was first found. The ratio of the total number of workers in all occupations between 45 and 54 to the workers of all ages employed in all occupations was 25.8 per cent; the percentage for those between 55 and, 54 was 12.2 per cent, and that for those 65 and over 4.4 per cent. Certain occupations having a large proportion of boys as well as those in which the vast majority of the workers were women were eliminated, because it was considered that they had no importance in a study of superannuation. Occupations in which the percentage of workers in the specified age groups was more or less than that for all occupations combined, present distinct problems. They were, therefore, analyzed separately. Selected occupations requiring strength and endurance or having special health hazards are included in Table II. This shows the relative percentage of workers 45 and over for all occupations and for eight in which the percentage of persons 45 to 54, 55 to 64 and 65 and over is less than in all occupations. One naturally expects to find a great decrease in the numbers 45 and over, and especially 55 and over employed in such exacting occupations as brass working, boiler making, glass making and pottery. Thus, of the brass workers 14.7 per cent were between 45 and 54, 5.3 per cent between 55 and 64, and 1.3 per cent 65 and over; of the steam boiler makers, 17.0 per cent were between 45 and 54, 6.1 per cent between 55 and 64, and 1.5 per cent 65 and over; and of the glass workers 11.7 per cent were between 45 and 54, 3.6 per cent between 55 and 64, and 0.8 per cent 65 and over. 209 Table II. Number and Per Cent of Employees 45 and over in Selected Industries in the United States, igoo Total number employed ^° Number of employees " Per cent of total Occupation 45 to 54 55 to 64 65 and over 45 to 54 55 to 64 65 and over All occupations. Marble and stone cutters.. Painters, glaz- ers, varnish- ers 23,957,778 54,382 276,231 20,709 33,079 287,427 25,870 13,200 47,378 6,187,927 14,339 69,681 5,204 5,938 47,042 3,822 1,950 5,575 2,926,122 5,264 27,406 1,686 2,103 15,789 1,394 691 1,737 1,065,375 1,498 7,759 419 527 3,783 360 208 392 25.8 26.3 25.2 25.1 17.0 16.3 14.7 14.7 11.7 12.2 9.6 9.9 8.1 6.3 5.4 5.3 5.2 3.6 4.4 2.7 2 8 Brewers and malsters Steam boiler makers Iron and steel workers " Brass workers . . Potters Glass making. . . 2.0 1.5 1.3 1.3 1.5 0.8 '° Twelfth Census of the United States, 1900, Special Reports, "Occupations." Table 2, p. 12. "/6id., Table 4, p. 18. " Includes foundries, blast furnaces- and rolling mills. A similar analysis based on the more recent 1910 census is im- possible because the age classification for 1910 does not extend beyond the age period 45 and over. Occupations which to a considerable extent are monopolized by young men form another group which shows a great decrease after 45. Among these are messengers, waiters, agricultural laborers, actors, clerks, bottlers and soda water makers. Many young persons on leaving school adopt teaching as a means of making a livelihood, until they can secure something better. Many young men work as agricultural lab- orers for a few years with the hope of eventually owning or renting a farm of their own. Clerking is also used as a stepping-stone by a large number of young men. In the case of actors, musicians and waiters, we have occupations in which youth and appearance are very important. One is, therefore, not surprised to find a relatively small number of persons 45 and over in these occupations. While accepting the conclusion that there are some industries in which fewer men past middle Jife are employed than the average for all industries, on the other hand it must be remembered that there are some factors which tend to favor the old man in industry, particularly in occupations requiring a high degree of skill. The high grade tool- maker can do good work at 65. the allround skilled machinist of 65 is, in many cases, more valuable than a man of 30. His experience in 14 2IO Operating different machines and his knowledge of different metals are invaluable to his employer. All employers whom the writer interviewed claimed that the old machinist was more reliable, wasted less material and succeeded better with apprentices than a younger man. The mill- wright or the carpenter over 60, while not as active as a young man, may be just as efficient in floor work. In six foundries employing 500 molders visited in the course of the study, only three men over 50 years of age were engaged in heavy floor molding. Ten men over 60 were engaged in light bench molding. This would seem to indicate that the molder does not last very long at his trade. Hayhurst, however, claims that foundry work is not an ex- ceptionally fatiguing occupation, but that it may be made so by contact with wet sand, dust, smoke, excessive heat during certain periods of the day, by speeding up, by monotony and by standing in awkward posi- tions.^^ The introduction of machinery has in some instances made work lighter for the old man and enabled him to continue longer in industry. In Newark, Ohio, a number of old glass bottle blowers who previously had been displaced, have been taken back as machine operators. Few employers dismiss old men who have been in their service over a long period of years. When the old man is no longer able to keep the pace, he is given a pensioner's job. Frequently old molders were found engaged in chipping light castings, and old machinists were doing light filing in the foundries and machine shops in which they had worked for years. Many employers pointed with pride to their old men's department. The question naturally arises as to how far, if at all, the industrial development of the years 1900 to 1910 has interfered with the prospects of the old man in industry. Here again the different classifications of those gainfully employed in the enumerations of 1900 and 1910 make comparison on any large scale exceedingly difficult. The classification in the 1910 census altered materially the content of certain groups of the 1900 census. For example, in 1910 apprentices in all industries except the building and hand trades, were all classified as "apprentices" without distinction as to either trade or industry. The figures for black- smiths taken from the 1900 enumeration appear under the heading of iron and steel and their products; data, for blacksmiths taken from the 1910 census appear in the various subdivisions of iron and steel indus- tries, namely foundries, blast furnaces and ^teel rolling mills, and thus are fairly comparable with the blacksmiths of 1910. Masons (brick and stone) in 1900 include apprentices, helpers and laborers; in 1910 masons appear under the heading of building and hand trades and include masons, apprentices and helpers. The classification of potters in 1910 " E. R. Hayhurst, Industrial Health Hazards and Occupational Diseases in Ohio, 1915, p. 131. 211 excludes managerial and mechanical pursuits not a part of the potter's trade. It was, however, found possible to compare the census figures for six occupations in 1900 and 1910. Table III shows the total number of persons, the number and the per cent of persons 45 and over in these occupations in 1900 and 1910. Table III. Total Number of Persons and Number 45 Years of Age and over, Employed in Selected Occupations, igoo, igio^ Employed in 1900 Employed in 1910 Occupations Total number 45 and over Total number 45 and over Number Per cent Number Per cent Blacksmiths Boilermakers (steam) 226,880 33,079 282,861 74,730 5,938 .5.^.011 32,4 17.0 18.7 38.4 14.7 7.3 241,270 39,284 430,814 202,156 21,293 28,350 86,586 8,015 86,428 69,770 3,624 2,103 35.8 20 4 Machinists 20 160,881 6i,'868 13,200 1 950 34 5 Potters 10 7 Telegraph and tele- phone linemen .... 14,765 1,068 7.4 "Twelfth Census of the United States, 1900, Special Reports, "Occupations," Table I, p. 7, Table 4, p. 16 ; Thirteenth Census of the United States, "Occupation Statistics," Table VI, p. 302. From the table it is evident that in six occupations, there has been a marked increase in the number of employees 45 and over. There has been a slight decrease between 1900 and 1910 in the percentage of potters and masons 45 and over. Under normal conditions the unskilled worker over 50 who is dis- placed by an industrial change or sickness will find it difficult to obtain another job. Studies of unemployment in Great Britain bear striking testimony to this fact. In an intensive study of 291 cases of unem- ployment at York, England, Rowntree and Lasker found that in 68 or 23.3 per cent of the cases, age was the primary, factor rendering difficuU the reabsorption of these workers into the ranks of the permanently employed. In regard to this factor in unemployment, the authors state "it is unfortunately indisputable that when a skilled worker gets past forty, he finds it very difficult to meet with an employer who is willing to give him regular work." In this respect, the conditions in England do not differ widely from those in the United States. The census reports indicate that there are certain unskilled occupa- tions which old men enter after they have been compelled to give up work in their principal occupations. There is a striking preponderance of old men in such occupations as those of janitor, city laborer, watch- 212 men for cities and boarding and lodging house keepers. Nearly 24.8 per cent of the boarding and lodging house keepers (male), in the United States in 1900^^ were between 45 and 54; 21.8 per cent were be- tween 55 and 64 and 15.2 per cent were 65 and over. Of the watchmen, pohcemen and firemen 21.9 per cent were between 45 and 54; 14.0 per cent were between 55 and 64 and 5.4 per cent were 65 and over. Of the janitors and sextons 21.8 per cent were between 45 and 54; about 17.9 per cent were between 55 and 64 and 9.7 per cent were 65 and over. In 1910,^° 52.0 per cent of the janitors, 63.4 per cent of the sextons, 41.3 per cent of the city laborers, 65.7 per cent of the city watchmen, and 55.0 per cent of the boarding and lodging house keepers were 45 and over. From the foregoing analysis the following conclusions appear jus- tjified: (i) many working mien are compelled between 50 and 60 to leave trades which impose a severe physical strain; (2) in some occu- pations in which experience, skill and directive ability are of great value, a man may retain his place until the age of 65 ; (3) even in occupations requiring great strength and endurance, there is some light work which old men can do; (4) a fairly large number of wage-earners, after they have been superannuated in their • principal occupations, find employ- ment as janitors, watchmen and city laborers, — occupations in which fully 50 per cent of the persons are past 50; (5) many employers retain old men who have been employed for many years, even after their greatest economic usefulness has passed; (6) a large percentage of the unoccupied persons 65 and over in the United States and Ohio are, in all probability, former wage-earners. The persons between 65 and 70 who are tmoccupied are either men who are totally or almost totally disabled, widows or unmarried women. There is a very little positive information as to the extent to which wage-earners save for their old age. Budgetary sudies are not satis- factory in this respect. As will be seen when results of the Hamilton survey are discussed, savings depend more on the personal equation, on a thrifty housewife and on the extent to which the family has been im- mune from sickness, than on income. It is impossible to estimate to what extent the postal savings and bank deposits represent the savings of wage-earners. Information relative to home ownership according to age given by the census is more useful. In 1900 of the 3,083,995 per- sons 65 and over in the United States, 847,069 or 27.4 per cent owned their homes free and 196,407, or 6.4 per cent owned them mortgaged. Of the 209,563 persons 65 and over in Ohio in 1900, 69,999 or 33.4 per cent owned their homes free, and 13,487 or 6.4 per cent owned them " Twelfth Census of the United States, 1900, Special Reports, "Occupations," Table IV, p. 16. "Thirteenth Census of the United States, 1910, "Occupation Statistics," Table VI, p. 430. 213 encumbered. A comparison miay be made between the number of farm homes owned in 1900 and in 1910. In 1910 the number of farmers (i, e. "farm operators") as given in the census tables in the various groups, is equal to the number of farms carried on by operators of the designated age counting one operator to each farm. Except for the owners of farm homes, the census of ipiq makes no attempt to classify home owners according to age groups. These figures are presented in the following table: Table IV. Number of Persons 65 and over Oismi/ng Farm Homes in the United States and in Ohio, 1900, igio" 1900 ' Number of persons 65 and over Number of farm homes owned Area Total Free Encumbered Number Per cent Number Per cent The United States Ohio 3,083,995 209,563 505,548 37,907 388,030 30,585 •76.7 80.6 100,413 6,359 19.8 16.7 1910 The United States. Ohio 3,949,524 261,810 554,570 32,007 362,468 24,406 65.1 76.2 79,693 3,860 14.3 11.7 .^^'^ ^^''^^ '^ compiled from: Twelfth Census of the United States, 1900, Population," Table 3, p. 110, Table 110, p. 724; Thirteenth Census of the United States 1910^ Population," Table 45, p. 416; Thirteenth Census Bulletin Agri- culture, Untied States, "Age of Farmers, by Color of Operator, Character of Tenure, and Size of Farm," Table 12, p. 25. From the foregoing figures it is apparent that about 35 per cent of the persons 65 and over in the United States in 1910 owned their homes, and that about 38 per cent of the same age in Ohio. This, of course, does not answer the question as to how far the wage-earners 65 and over, and above all, the wage-earners who are no longer able tQ work, have saved for old age. CHAPTER XVI OLD AGE IN HAMILTON AND CINCINNATI Dr. John O'Grady In order that the Commission might be able to judge how men past 50 fare in different occupations and to what extent they have saved for old age, it was considered necessary to make a survey in one or more typical industrial centers in the state. After consultation with persons intimately acquainted with industrial conditions in Ohio, the city of Hamilton was finally selected. It seemed to be the general opinion that in no other city could one get a more accurate picture of the economic condition of the aged wage-earner. In 1910 Hamilton had a population of 35,274 and its population today is at least 40,000. According to the latest figures of the Industrial Commission of Ohio there are in the city 12,945 wage-earners employed in various types of industries. The principal industries of the city are the foundries and machine shops employing 6,665 persons, and paper and pulp mills employing approximately 2,000. To these must be added tobacco factories, woolen and worsted mills, cotton factories and a numiber of minor industries. On the basis of origin the population of Hamilton naturally divides itself into three groups. In the first place there is the native popula- tion, or the people who were born and reared on the farms in the sur- rounding counties. Some of these moved to town at a very early age and acquired skill in trades. Some grew weary of the country when they were past middle life and resolved to seek better opportunities in the town. These are mostly found in the unskilled trades. Others feeling' that farm labor was becoming too severe on account of their advancing years inoved to town in order to secure easier work. These are employed as watchmen, city laborers, janitors and frequently as general factory laborers. The second important element in the population is the German im- migrant group. Nearly all the Germans in Hamilton came over in the late fifties and early sixties. They are found principally in the skilled trades. The third element in the Hamilton population is made up of unskilled workmen, who have migrated from the mountainous districts of Kentucky and Tennessee during the past fifteen years. In choosing the section of the city to be surveyed it was thought that an effort should be made to select one populated principally by (214) 2IS wage-earners, and a section, moreover, containing the different wage- earning elements of the population. The section finally selected had a total population of about 15,000. The total number of families in the section was approximately 3,600. While every family in the district was visited by the writer and his assistants, detailed information was obtained only in regard to those families having some member over 50 years of age. When both hus- band and wife were over 50, detailed information was in 'most cases obtained only in regard to the husband. When there was no husband in the household detailed information was obtained in regard to the woman. During the course of the Hamilton survey, the officials of the Na- tional Social Unit Organization in Cincinnati volunteered to secure in- formation in regard to all persons over 60 in the territory covered by their organization. With the cooperation of their block workers they filled out and returned 416 schedules. While the information obtained in Cincinnati was not so extensive as that secured in Hamilton, it is help- ful in understanding the conditions of the aged wage-earner in a large city. The extent of the two investigations is indicated in Table I. Table I. Total Number of Persons Included in this Study, by Sex and Age Groups: Hamilton and Cincinnati Hamilton Cincinnati Age Males Females Males Females Number Per cent distri- bution Number Per cent distri- bution Number Per cent distri- bution Number Per cent distri- bution SO to 54..-.. 223 238 223 105 86 37 20 10 2 23.6 25.2 23.6 11.2 9.1 3.9 2.1 1.1 .2 62 77 118 68 71 62 28 8 4 12.7 15.7 24.2 13.9 14.6 10.7 5.7 1.7 .8 55 to 59.... 60 to 64.... 65 to 69.... 70 to 74.... 75 to 79.... 80 to 84.... 85 to 89.... 90 and over. 80 55 37 28 14 1 1 37.0 25.5 17.1 12.9 6.5 .5 .6 76 38 36 35 13 2 38.0 19.0 18.0 17.5 6.5 1.0 ■ Total .... 944 100.0 488 100.0 216 100.0 200 100.0 Of the 1,432 persons studied in Hamilton 1,045 were native-born, and 387 foreign-born. Of the native-born, 734 were bom in Ohio and 311 in other states, principally Kentucky; of the foreign-bom, 299. were bom in Germany and 88 in other foreign countries. Of 416 persons studied in Cincinnati, 210 were of native and 206 of foreign origin. 2l6 Of the native-born, 127 were bom in Ohio and 83 in other states; and of those of foreign birth, 180 were born in Germany and 26 in other foreign countries. The countries of origin of the foreign-born group studied in the two cities are as follows : Table II. Foreign-born Persons Studied, by Country of Birth: Hamilton and Cincinnati Country of birth Hamilton Cincinnati Total Austria-Hungary Belgium France , Germany Great Britain, Australia and Canada Greece Holland Ireland Italy Russia Sweden Switzerland Syria Total I 6 1 20 299 4 1 4 22 7 5 1 16 1 180 2 10 387 206 12 1 26 479 6 1 4 32 7 5 1 18 1 593 Most of the foreign-born persons studied in Hamilton and Cincin- nati came to this country at an early age and have been long time res- idents of Ohio. This fact appears from the following figures in the Hamilton study: Table III. Length of Residence in the United States and in Ohio of the Foreign- born: Hamilton Years In the United States Number •Per cent distribution In Ohio Number Per cent distribution Less than 10 10 to 19.... So to 29.... 30 to 39. . . . 40 or over. . Total .. 2 14 56 104 211 .6 3.6 14.5 26.9 54.5 7 23 68 95 186 1.9 6.2 16.8 25.4 49.7 387 100.0 374 100.0 From the above figures it will be seen that 81 per cent of the foreign-born in the Hamilton study have been in the United States 30 years or more and 75 per cent of the 374 reporting have been in Ohio for as long a period. In Cincinnati, where the group is on the whole 317 much older, the proportions are still higher. More than 90 per cent of the foreign-born have been in the United States 30 years or over, and over 80 per cent have been in Ohio for the same period. It may be said, therefore, that immigration has had very Httle influence on the careers of the persons studied. As far as opportunities were concerned the early immigrants who settled in Hamilton and Cincinnati were in prac- tically the same position, as the native-born. A large number of the German immigrants came to this country before they had yet reached their majority, in many cases when they were only four or five years old. Those who migrated to Hamilton and Cincinnati from other states were in a much more unfavorable position than the immigrants. Most of the former were past 30 when they left their homes in Kentucky, Tennessee and elsewhere. That considerably over half of them had lived less than 20 years in Ohio is shown by the next table. Table IV. Length of Residence in Ohio of_ Native Americans Born in other States: Hamilton Years in Ohio Number Per cent distribution Less tl1a.11 10 91 87 39 36 58 29.3 10 to 20 28.0 21 to 30 12 5 31 to 40 11 6 18 6 Total 311 100 In their early life these people lived under a rather primitive system of agriculture. Work in a modern industrial establishment was entirely new to them. Their standard of living was in entire harmony with their primitive economy. _ They could exist on half the amount necessary to maintain the ordinary unskilled workman. But high as their wages were in their new employments compared 'with their standard of Uving, there was little thought of saving for the future. The children of these persons have made some progress beyond their fathers, but not to the same extent as the children of European immigrants. Table V contains detailed information in regard to the age and marital condition of the persons studied in Hamilton and Cincinnati. When the husband and wife were over 50, detailed information was not obtained in regard to the wife except in a few cases. It was felt that her circumstances were too closely bound up with those of her husband to make her a subject of special study. 2l8 Table V. Age and Martial Condition by Sex. Hamilton and Cincinnati Males Females City Di- Di- age Total Mar- ried Single Wid- owed vorced and sepa- rated Total Mar- ried Single Wid- owed vorced and sepa- rated Ham- - ilton 50-54 . 223 186 13 19 5 62 7 14 33 8 55-59 . 238 201 9 24 4 77 6 12 52 7 60-64 . 223 185 7 28 3 118 2 18 94 4 65-69 . 105 84 5 13 3 68 8 58 2 70-74 . 86 66 2 18 71 3 67 1 75-79 . 37 13 24 52 7 44 1 80-84 . 20 ■9 11 28 2 25 1 85-89 . 10 2 9 i' 1 1 8 4 8 4 90-over Total 944 753 37 139 15 488 23 114 329 22 Cin- cin- nati 60H64 . 80 60 7 12 1 76 20 7 48 1 65-69 . 55 40 6 9 38 7 3 28 70-74 . 37 20 3 14 36 6 2 28 75-79 . 28 18 10 35 3 1 31 80-84 . 14 1 1 9 1 1 4 13 2 13 2 85-89 . 90-over 1 Total 216 148 17 50 1 200 36 13 150 1 In old age, martial condition, especially as regards women, is. very important. .The woman who becomes a widow after 50 is ill prepared to make her own living. She must, therefore, depend on her children or on the property left her by her husband. If her husband was a wage- earner, the most she can expect to inherit is a little home. One hundred and sixty-six or 50.8 per cent of the 329 widows in the Hamilton survey OAvned their own homes. While the children remain unmarried, they contribute to the maintenance of their mother, but after marriage she can no longer depend upon them with any feeling of security. The single woman who has had to make her own living is also insecure in her old age. After 50 she finds it difficult to obtain steady employmlent and her wages, as a rule, have not been such as to permit much saving for old age. Only 37 of the 114 single women over 50 had any savings. The small wage-earner, if he has taken good care of his health and has not been engaged in exceptionally hazardous occupations, is not 219 compelled to retire much before 70. His wages after 60 may be low but the needs of old people who enjoy good health are few. If he has a wife depending on him, as is very frequently the case, her usefulness in the household will more than offset the cost of her maintenance. Persons past 60 are sometimes considered to have reached their second childhood, when they should depend on their children just as minor children depend on their parents. Few think of the aged as obliged to maintain themselves, still less as having dependents, and yet such is not infrequently the case. Men sometimes postpone marriage until late in life and sometimes they marry a second time. In both cases they may have minor children dependent upon them after they are past 60. Again, there may be a defective child in the family or one who has become a permanent invalid. It was found that 15 per cent of the 1,432 persons over 50 in Hamilton had one or more dependents; 12 per cent, two or more dependents and 10 per cent, three or more dependents. Seven per cent of the 416 persons over 60 in Cincinnati had one or more dependents and 5 per cent had two or more dependents. In studying the problem of old age it is important to learn to what extent persons past middle life are employed and in what occupations they find employment. Information was obtained relative to the occu- pations of 1,380 of the 1,432 persons studied in Hamilton and 379 of the 416 persons studied in Cincinnati. These are shown in the following tables : Table VI. Occupation of Males Studied, by Sex and Age Groups: Hamilton and Cincinnati Hamilton Cincinnati Occupation 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 75 to 79 80 or over To- tal 60 to 64 65 to 69 70 to 74 75 to 79 80 or over To- tal 5 10 2 "6 3 3 4 15 3 1 7 1 2 9 1 4 3 15 5 12 1 1 5 1 2 4 2 ii 2 6 1 8 1 1 18 52 6 2 20 9 18 3 9 7 49 1 7 2 1 Business, retail merchants Letter carriers and city employees 6 3 1 1 4 17 5 Agent — sales , collecting , purchasing, real estate.. Clerk, bookkeeper Bartender, brewery "i 1 1 =1 1 1 2 2 1 1 7 1 1 1 3 Blacksmith and black- smith's heloer B ox maker, cabinet maker 1 1 3 Brakeman , switchman , 2 3 15 Butcher baker miller.... 3 3 "i 1 6 Carpenter, woodworker . 1 5 220 Table VI. Occupation of Males Studied, by Sex and Age Groups: Hamilton and Cincinnati — Concluded Hamilton Cincinnati Occupation 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 75 to 79 80 or pver To- tal 60 to 64 65 to 69 70 to 74 75 to 79| 80 or 3ver| To- tal Cementer, plasterer, bricklayer 3 1 4 4 3 5 21 13 4 4 14 24 6 2 19 274 82 23 14 2 2 1 2 1 1 ■ < • < ■ > • 5 Cigar maker 2 6 3 2 1 8 6 2 1 1 3 Cooper, safe worker Core maker, pattern maker 1 1 2 ... 3 Dairy worker, farm hand. Elevator operator, mes- 2 8 5 3 1 2 2 3 1 5 3 "4 1 8 3 1 1 1 1 1 4 3 2 9, Engineer^ocomotive, or stationary, and railway 2 9 2 1 4 82 24 5 3 1 6 Executive, foreman, sup- erintendent 8 1 1 2 72 29 10 5 4 Farmer , truck gardner . . . 1 Harness maker, tanner. . . 5 Janitor, porter, sexton, 4 57 22 6 5 7 40 4 1 1 15 2 1 1 1 7 1 '"i 1 1 2 1 1 "i "i 1 3 Laborer 14 Machinists and machinist's helper R Molder 2 Painter," trimmer, 7 Peddler assorter of waste 2 Polisher sander 3 1 1 3 2 2 1 1 2 5 2 11 5 6 1 2 38 7 133 31 1 1 1 1 Stonemason, granite cut- ter 1 Stove maker, mounter, 9 1 9 Street cleaner 1 1 2 1 Tailor 3 1 1 3 1 8 6 1 2 1 2 6 '5 Tinner hoilermaker 1 12 'io Watchman and signal man 10 4 22 10 ■ 4 "9 9 5 2 39 1 4 'is 2 "27 3 2 1 . . . 2 5 7 10 7 9 13 6 18 11 3 56 Not stated 98 1 Total 223 238 223 105 86 37 32 944 80 55 37 28 16 216 221 Table VII. Occupation of Females Studied, by Sex and Age Groups: Hamilton and Cincinnati Hamilton Cincinnati Occupation 50 to 54 65 to 59 60 to 64 65 to 69 70 to 74 75 to 79 80 or over To- tal 60 to 64 65 to 69 70 to 74 75 to 79 80 or over To- tal Housewife 26 14 9 3 1 2 4 2 1 33 16 4 3 4 44 13 2 4 2 21 5 1 3 13 2 10 2 2 4 151 52 18 14 7 3 17 2 203 21 48 13 3 25 3 1 18 3 20 4 1 7 '"i 118 Domestic service, janitor work, etc 9R Dressmaker, tailor, etc... Rooming or boarding house keeper 6 Retail business 1 1 1 Professional work 1 1 1 Laborer (not otherwise classified) 9 2 1 "2 4 2 1 2 5 2 1 Miscellaneous 1 4 1 ■5 8 47 4 30 7 54 28 9 35 15 8 36 Not reported 5 Total 62 77 118 68 71 52 40 488 76 38 36 35 15 200 Of the 416 persons in regard to whom information was obtained in Cincinnati, 216 were men and 2CX) were women. Eighteen of the men were engaged in business and the professions; 66 were skilled or semi-skilled workers; 38 were unskilled; 56 were unoccupied and 28 made no statement regarding occupations. Two of the women were engaged in business or a profession; seven were skilled or semi-skilled workers; 146 were unskilled workers, 36 were unoccupied and 9 made no statement regarding occupation. The women who were classified as unskilled workers included 118 who were keeping house for their hus- bands, children or friends. Of the 1,432 persons in Hamilton 944 were men and 488 women. Of the 913 men whose occupations were stated 99 were engaged in the professions or in business of various kinds. Only 50, however, had attained prominence in the professions or had large businesses. Two hundred and ninety-three were skilled or semi-skilled wage-earners, 388 were unskilled wage-earners, and 133 were unoccupied, that is, had no regular employment. The foregoing table reveals many interesting facts. It will be noted that of the 913 Hamilton men reporting the facts relative to occupation only 133 were unoccupied. The distribution of the unoccupied among the dififerent age groups appears in the following tabular statement : 222 Table VIII. Per Cent of Men Unoccupied , by Age Groups: Hamilton Age groups- Number reporting in regard to occupa- tion Unoccupied Number Per cent 50 to 54 217 238 213 96 85 35 29 8 10 22 9 39 18 27 3.7 55 to 59 4 2 60 to 64 10.3 65 to 69 9.4 70 to -74 45 9 75 to 79 51.4 93.1 . . Total 913 183 14 6 This table indicates that except for those over 70, age; is not such a prominent factor in retirement as it is sometimes supposed. Some may suspect that the employment of so many old men is due to war con- ditions, but the writer failed to find more than five men who had re- turned to work since the outbreak of the war. Some allowance should be made for the fact that a large percentage of the aged wage-earners in Hamilton have worked in the same shop for the greater part of their lives, and that consequently the employers were more willing to provide easy jobs for them in old age than for men who had joined the working force late in life. From the Cincinnati figures it appears that of the 188 men in regard to whom information relative to occupation was obtained, 56 were unoccupied, and of these only 14 were under 70 years of age. Of the 467 women reporting in regard to occupation in Hamilton, 113 or 23.2 per cent were gainfully employed; 151 were keeping house for husbands, children or relatives ; the remaining 203 were unoccupied. It is particularly noteworthy that, while a large number of the women were unoccupied, more than one-fifth of the total number found it necessary to work for income. The unskilled, however, included 151 women who were keeping house either in their own homes or in the homes of friends. Two hundred and three women were unoccupied; in other words they were not contributing to. the maintenance of the family by household work nor were they engaged in gainful occupa- tions. Twenty-four women were engaged in professions or in small business enterprises such as keeping boarders and lodgers. The skilled and semi-skilled trades employed a large quota of the old men in Hamilton. The men over- 50 in the skilled trades were not, as a rule, required to do hard work. The machinists, safe workers, pat- tern makers and core makers seemed able to hold their own because of their superior skill. The molders over 50 who were interviewed were all 223 engaged in light bench molding. Of the unskilled workers, 274 were classified as laborer. Most of these were engaged in light work in the different factories. It was found that the old men's jobs such as street cleaning, janitor, bill collector, watchman and city employee gave employment to 58 of the 913 men who reported their occupations. Information was obtained in regard to the principal causes of re- tirement of 87 of the 133 men reported unoccupied in Hamilton as shown in Table IX. Disease, sickness or accident was the cause of retirement in 61 cases' and old age in 26 cases. Table IX. Principal Cause of Retirement of Men, by Age Groups: Hamilton Age group Disease and accident Old age 50 to 54 15 12 13 16 3 1 1 55 to 59 60 to 64 1 65 to 69 ; . . . 5 70 to 74 11 75 to 79 5 4 Total .... 61 26 These figures, as well as the general observation of the inves- tigators during the course of the study, seem to indicate that sickness, disease and accident are important factors in shortening the period of man's economic usefulness. Many of the workers interviewed stated that they began to fail after 50. Machinists and pattern makers com- plained of defective eyesight and the molders of rheumatism. Asi a rule they paid little attention to these disorders imtil there was a breakdown compelling them to give up work for two or three months. Illnesses were more important than any other caUse in bring- ing about premature superannuation and frequently required the ex- penditure of all previous savings. There was every indication that for many wage-earners over 50 in Hamilton, the problem of sickness was really serious. The maladjust- ments, neglects and excesses of early life were then making themselves felt. One hundred and fifty-five of the men interviewed reported them- selves as afflicted with definite disorders of various kinds, such as rheu- matism and kidney, bladder and stomach troubles. These ailments, accentuated by age, frequently compelled them to be absent from work for two or three months at a time. The census figures analyzed in Chapter XV show that men over 50 tend to change their occupations in order to secure lighter work. An attempt was made to discover how far this tendency was substantiated 224 by Hamilton experience. It was found that many men of weak physique enter occupations like molding, blacksmithing and boiler making, dis- covering that they are not equal to the strain when it is too late. It was also found that 8i wage-earners over 50 had been compelled to change their occupations. Of these, 49 claimed that they changed be- cause of sickness, g on account of the scarcity and irregularity of work, II because of accident, 12 due to failing strength and old age. Table X shows in detail the causes of change by age and occupation. Table X. Number of Persons Changing Occupations and Reasons for Change, by Former Occupation and by' Age Groups: Hamilton Cause and occupation 50 to 54 55 to 59 60 to 64 65 to 69 70 to 75 Total Disease and sickness Baker 2 1 1 1 1 3 1 2 Blacksmith 2 1 3 Bricklayer 2 Carpenter 1 1 2 Farm laborer 1 4 1 3 3 General laborer 7 Iron worker 2 Machinist 3 Miner 1 1 Molder 4 3 4 2 3 10 Painter g Pattern maker 1 1 Railroad switchman. 1 3 1 Safe worker 3 Sales agent 1 1 Stonemason 1 1 2 Total 22 1 1 8 18 1 49 Accident Brewery worker.... 1 Carpenter 1 1 2 General laborer 1 Machinist 1 1 Millwright 1 1 1 1 Painter . . .' 1 • 1 Railroad brakeman.. 1 1 2 2 Total 4 1 7 .. IT Scarcity and irregularity of work Boot and shoemaker 1 Caroenter 1 2 8 1 2 Cooper 2 Saddler Stonemason 1 Total 4 4 1 9 225 Table X. Number of Persons Changing Occupations and Reasons for Change, by Former Occupation and by Age Groups: Hamilton — Concluded Cause and occupation 50 to 54 55 to 59 60 to 64 65 to m 70 to 75 Total Old age and failing strength Iron worker . . . 1 2 1 Molder 3 1 6 Potter 1 1 1 1 ....^.... 2 ■1 1 Total 3 1 5 2 1 12 The idea of providing for old age is fundamental in all our human activities. Business and professional men work hard from morning until night during the productive years to provide an adequate means of livelihood for old age or for wife and children after their death. For workmen saving for old age is exceedingly difficult. If his wife is a good manager or if he is thrifty and receives a fairly high wage, he may be able to set aside a small part of his earnings. After a time through sickness, he may be forced to give up his work for a month or more. The greater part of his savings may then be required either to pay his doctor's and druggist's bills or to take care of the running expenses of the house. After another period of saving, his wife or one of the children may become ill or he may be temporarily out of work. However, if the wage-earner is sufficiently fortunate to escape somie of these hazards, if his wife is a good manager and if he has received a fairly high wage, the chances are that by 50 he will have saved something for old age. In towns where home owning is possible for wage-earners, the chances are that his savings will be represented by a home worth from $1,500 to $3,000. With his increased sickness risk and his greatly depreciated earning power after 55, he is indeed fortunate if he owns his home free of debt at 65. Of the 1,432 persons studied in Hamilton, 525 or 36.6 per cent owned their homes free from encumbrance and 138 or 9.6 per cent owned them mortgaged. Of the 416 persons studied in Cincinnati 98 or 23.6 per cent owned their homes. That the smaller proportion of home owners in Cincinnati is probably due, at least in part, to the higher values of property in that city is suggested by Table XI which shows for the two cities the total number of persons studied who owned their homes, by the value of the" homes. The Hamilton data in regard to titles as well as the data relative to mortgages in Table XII, were in every instance checked with the figures in the county recorder's office. 15 226 Table XI. Persons Owning Homes, by Value of Homes: Hamilton and Cincinnati Value of homes Hamilton Number Per cent distribution Cincinnati Number Per cent distribution Less than $1,000 $1,000 to $1,499 1,500 to 1,799 1,800 to 2,199 2,200 to 2,499 2,500 to 2,999 3,000 to 4,000 Over $4,000 ... Total 41 81 107 137 76 79 93 49 6.2 12.2 16.1 20.7 11.5 11.9 14.0 7.4 663 100.0 1 4 5 8 2 10 15 26 71 1.4 5.7 7.0 11.3 2.8 14.1 21.1 36.6 100.0 In Hamilton home ownership meant much for aged persons who had children. One of the children was usually willing to maintain the parents in return for the use of the home and with the prospect of own- ing it after their death. For the aged persons who were able to work, ownership of a home was also most helpful. The wages which they received might be small, but the fact that they had no rent to pay made the problem of living much easier. Aged home owners who had no children living, or who were unable to work, frequently rented a por- tion of the house, retaining one room for themselves. Since the rent was usually not more than $i6 a month, these old people had a difficult time in making ends meet. Of the 663 homes owned by the persons studied in Hamilton, 435 were owned by wage-earners or widows . of former wage-earners and 228 by business or professional men or their widows. One hundred and ninety-six of the wage-earners owning their homes were relatively skilled or semi-skilled and 239 unskilled which means that 45.3 per cent of the total skilled wage-earners and 31.6 per cent of the total unskilled wage-earners owned their homes. Home owning was noticeably more common among immigrants than among the native-born. Approximately two-thirds of the Germans owned their homes and among other foreign-bom the proportion was almost as high. Among the natives of Ohio every other person visited was a home owner, but among the natives of other states home owning was rare. The small number of persons from other states owning their homes is due to the predominance of certain groups, already referred to, from the backward districts of the south, whose members have not yet acquired the art of saving. The data relative to mortgages are given in Table XH. 227 Table XII. Extent to which Homes were Mortgaged, by Value of Homes: Hamilton Number Number of homes with mortgage Value of of homes homes without Less 4 but § of mortgage than 4 of less than 1 value or Total value of value more Less than $1,000 33 2 5 1 8 $1,000 to $1,499 67 2 8 4 14 1,500 to 1,799 70 12 17 8 37 1,800 to 2,199 110 14 9 4 27 2,200 to 2,499 59 6 9 2 17 2,500 to 2,999 65 3 7 4 14 3,000 to 4,000 82 5 5 1 11 Over $4,000 39 4 3 3 10 Total 525 48 63 27 138 A study of this table reveals that approximately one home in four was found to be mortgaged. Moreover the majority were heavily encumbered. Of the 138 encumbered houses, 90 or 65.2 per cent, were mortgaged to one-third of their value or over and 27 or 20.0 per cent were mortgaged to at least two-thirds of their value. Of the home owners in Hamilton 198 had property or other means in addition to their homes; among persons not owning homes 119 had property or other means. Table XIII shows the number of persons having property or other means exclusive of homes and the value of such property or means. In this table seven of the 198 home owners with additional property or other means are not include, because they did not report the value of their property. Table XIII. Persons having Property or other Means, with and without Homes, by Valm of Such Property: Hamilton property- Persons having property or other means Value of In addition to homes Without homes Number Per cent distribution Number Per cent distribution Less than $500 80 14 30 8 15 3 5 15 21 41.9 7.3 15.7 4.2 7.8 1.6 2.7 7.8 11.0 80 7 9 6 6 67.2 5.9 7.6 6.0 4.2 $500 to $999 1,000 to 1,499 1,500 to 1,799 1,800 to 2,199 2,200 to 2,499 2,500 to 2,999 1 4 7 ■ .8 3.4 5.9 3,000 to 4,000 : Over $4,000 Total 191 100.0 119 100.0 228 It will be noticed that most of those who did not own their homes lad very little saved. The ownership of a home is the ideal which the wage-earner sets before him in cities where home ownership is possible for him. That there is nothing which the workman in America dreads so much as a pauper's grave is clearly demonstrated by the fact that 38,373>272 industrial insurance policies having a face value of $5,193,- 330>295 were in force in the United States in 1917.^ The necessity of providing for funeral expenses and the other immediate needs arising from the death of the bread winner seemed to be quite generally rec- ognized by wage-earners in Hamilton. Of the 1,432 cases studied 793 ^^ 55-4 per cent were carrying Hfe insurance in one form or another, [n 387 or nearly half of the cases the amount of the policy was less than $200, while only 168, or approximately one person in five, carried pol- icies of $100 or more. Two hundred and nine of the 416 persons studied in Cincinnati carried life insurance in some form. Table XIV shows the number of persons carrying insurance and the value of the policies. This table does not include 84 persons in Cincinnati who carried pol- icies but did not report their value. Table XIV. Persons Carrying Life Insurance, by Value of the Policy: Hamilton and- Cincinnati Value of policy Hamilton Number Per cent distribution Cincinnati Number Per cent distribution Less than $100 $100 to $124 125 to 150 to 175 to 200 to 225 to 250 to 300 to 400 to to 600 149. 174. 199. 224. 249. 299. 399. 599. 999. 1,000 to 2,000. Dver $2,000 Total 69 84 60 139 35 70 10 23 32 86 17 146 22 798 8.7 10.6 7.6 17.6 4.4 8.8 1.8 2.9 4.0 10.8 2.1 18.4 2.8 100.0 7 20 23 18 1 8 4 3 6 13 4 10 125 5.6 16.0 18.4 14.4 0.8 6.4 3.2 2.4 4.8 10.4 8.2 8.0 6.4 100.0 The striking fact about insurance in Hamilton is the prevalence of industrial insurance among the most poorly paid unskilled wage- earners. Many of the skilled wage-earners were provided for by their ' The Insurance Year Book, 1917, p. 284. ;229 unions and, therefore, did not feel the need of taking out an industrial policy. Ninety-seven of the 1,848 persons in Hamilton and Cincinnati were receiving military and seven were receiving blind pensions. Sickness insurance was found much less generally than life insur- ance. Fraternal sickness insurance, however, has made considerable progress among the skilled wage-earners and men of small means in Hamilton. One hundred and six of the persons studied were protected against sickness by fraternal insurance; 8r of these were members of one fraternal, 13 of two fraternals and three of four fraternals. When aged persons who have been unable to save lose their economic usefulness, they must depend on their children, on relatives or on public charity. Three hundred and fifty-four old, or invalided persons in Hamilton were dependent on children or relatives. One hun- dred and fifty of these were dependent on married children, all with families of their own ; 144,' on unmarried children, and the remaining 60, on relatives. Forty-eight of the 416 aged persons studied in Cincinnati were dependent on their children and 13 on other persons. While one or more of the children remain unmarried, the position of the aged parents, it was found, was rather securfe, but once the chil- dren married, their relations with the parents were entirely changed. The aged parents, when asked if they could expect any assistance from their children, generally replied that the children already had sufficient responsibilities of their own. This was particularly true in regard to the children of wage-earners. In the case of children in better circum- stances the parents frequently found it difficult to get along with a son- in-law or a daughter-in-law. The daughter might have been willing to have her aged parents in the home, but her husband objected; or the son might have been willing to maintain his aged parents but found that they had friction with his wife. And in this connection, it is well to remember that the fault is not all on the side of the children. The old people have been regulating the affairs of the home for so long that they find it difficult to relinquish their authority after the children marry. From the Hamilton study it appeared that the maintenance of the aged parents or parent often devolved on one of the children. This one, it was found, was frequently compelled to remain unmarried in order to care for the parents. Seventy-three of the 144 unmarried children providing for their parents claimed that they had been com- pelled to remain unmarried. For women especially this is a serious hardship. After maintaining themselves and their parents they have little left to protect themselves against the hazards of sickness and old age. The Hamilton study and the information supplied by the National Social Unit Organization in Cincinnati together with the writer's per- sonal observation suggest the following conclusions relative to the problem of old age. I. The problem of old age, strictly speaking, does not become very serious for male wage-earners before 65. This does not necessarily mean that they can obtain work after this age, but that their inability to do so is not as a rule due to advancing years. The fact that many men, between the ages of 55 and 65, are) unable to obtain work is due in part to partial or total disability resulting from sickness or accident. Super- annuation is, therefore, very closely connected with industrial accidents and sickness. If proper care is not paid to rehabilitating the victims of industrial accidents or serious sickness, the chances are that they will be superannuated prematurely. II. The fact that men leave certain occupations between 50 and 55 does not necessarily mean that their occupations are exceptionally injurious to health. It may mean that without guidance in the selec- tion of a vocation they have chosen occupations ill suited to their physical powers. Greater care in selecting occupations in life would, therefore, do much towards prolonging the period of economic useful- ness. The allround skilled mechanic has a longer working life than the master of one process or the unskilled workman. III. There is no one for whom the problem of old age is as seri- ous as for the widow whose husband has died and left her property- less. In cases where the husband's death is preceded by a long period of sickness, it is more than likely that little can' be saved for the mainte- nance of the aged wife. She has been unaccustomed to work for a living and therefore finds it difficult to make the readjustment. Some widows in Hamilton kept boarding houses or took in washings in order to earn a livelihood. IV. It is very difficult, if not impossible, for the majority of wage- earners to save an amount adequate to their support in old age because of sickness, unemployment and other hazards to which they are exposed. V. The superannuated wage-earner may expect aid from his chil- dren before they get married, but after marriage he can no longer rely on them with any sense of security. VI. Every possible effort should be made to keep old men at work, except where their health has been permanently impaired, since they are much happier when at work than when idle. If the old man is unable to do hard work, he can obtain a job as a street cleaner, a watch- man or a janitor. There are also a number of light occupations in general factory work which can be filled by old men. Much can be done by having public employment offices pay particular attention to adjusting old men to the positions for which they are qualified. Munici- palities might well follow on a larger scale the precedent set by many employers in having their light work done by old men or others unquali- fied for hard work. 231 VII. No matter how much is done to prevent premature super- annuation by more adequate provision for the health of wage-earners, by vocational guidance or by securing special work for old men, the problem of superannuation will still remain, even though in a less ac- centuated form. There will always be the propertyless old woman of 65 or even of 60 who is unable to earn a livelihood. There will still be the problem of the man who has been prematurely superannuated by excessive physical strain, sickness or accident; and there will always be the man who is unable to work because he is too old. VIII. A large proportion of the men studied (in Hamilton, four out of five) still had wives living. Any pension scheme for wage- earners should take into account the wives as well as the aged wage- earners. A pension for the wage-earners only would be inadequate. IX. A large proportion of all the persons studied were either native to Ohio or had been in the state for many years. In Hamilton, where information on this point was available those native to the state together with those who had lived in Ohio thirty years or longer con- stituted more than three-fourths of the entire group. Their condition in old age is therefore quite properly the concern of this state. CHAPTER XVII CARE OF THE AGED AND SICK IN OHIO INFIRMARIES Dr. John O'Grady In Ohio, the care of public health and administration of outdoor relief are primarily functions of the township or municipal corporation. The health officials of the township, village, or city are obliged, on receiving notice from attending physicians, to take proper measures in order to prevent the spread of communicable diseases. When cases of needy persons are brought to the attention of the township or city officials, they must investigate these cases; and, having satisfied them- selves regarding their worthiness, must provide relief in the form of food, clothing or medical aid. There is nothing in the law to prevent them from doing that constructive work without which relief giving does more harm than good. But the local officials in Ohio are as ill qualified for this work as they are for the care of public health. The township trustees are elected for a short period of time. They have merely a passing interest in these particular problems. Unfortunately the same is true of the officials of villages and smaller towns. Sometimes the local officials pay no attention to the reports of physicians regarding con- tagious or infectious diseases. Diseased persons are permitted to mingle indiscriminately with other members of the community. Some townships and cities, actuated by false economy, provide no relief or an insufficient amount. One city will not accept the sick poor in its municipal hospital on the ground that the institution should be self- supporting. On the other hand, many cases have been brought to the writer's attention in which the townships after a short time exhausted their funds by indiscriminate relief giving without sufficient investigation or any constructive work. Four cities in the state, — Columbus, Akron, Toledo and Dayton — administer outdoor relief through privately organized charities, — a plan which undoubtedly makes for greater efficiency and economy. The pri- vate charities have the machinery and experience necessary to do the effective work, and the administration of public relief does not impose any serious additional burden upon them. If a city department is to do equally efficient work, it must incur the expense of developing a similar organization along parallel lines. (232) 233 CONDITIONS FOR RELIEF The relief granted by the township or municipality in Ohio is sup- posed to be of a temporary character. When the township trustees or proper city officials are of the opinion that a particular case need§ per- manent relief, they are required to notify the superintendent of the county infirmary. It then becomes the duty of the superintendent to investigate the case and decide whether the person is to be accepted as a county charge. In making this decision the superintendent has to face many difficulties. The individual referred to him may be an unsuitable case but it may be difficult to refuse relief because of the political con- nections of the township trustees. In some of the counties studied the superintendent of the infirmary has been compelled to accept unsuitable cases because the township trustees insisted on his doing so. In two counties, contrary to the letter and spirit of the Ohio law, the adminis- tration of relief had been placed in the hands of clerks associated with the commissioners' offices. The interpretation of the words "temporary" and "permanent" relief seems to be a mooted question -in Ohio counties. The township trustees try to refer the cases that come under their charge to the county as soon as possible; the county in turn is anxious to limit its expenditures for poor relief. In consequence, one frequently finds two opposing interpre- tations of the words "temporary" and "permanent." Some townships have a poor fund entirely insufficient to meet the demands ; others are extravagant in the management of the fund; while a third group has adequate funds and exercises great care in the distribution of relief. The first two groups have very little left in their treasuries towards the end of the year. The county superintendent, then^ must either give a lenient interpretation of the law in their case, or permit their poor to suffer. In the third group, by a strict interpretation of the law, the superintendent of the county infirmary can compel the townships to maintain all persons whom he does not consider desirable to move to the infirmary. In one county the superintendent made a rigid rule that the townships should maintain all persons needing relief for a period of one month. In a number of counties visited the infirmary superintendent declared that he accepted as county charges only those whose circum- stances were such as to indicate the necessity of relief for an indefinite or considerable period of time. This latter seems to be the only inter- pretation which the state law will admit. Section 3476 of the General Code provides for the relief of the poor by the township trustees as follows : Subject to the conditions, provisions, and limitations herein, the township trustees of each township, or the .proper officials of each municipal corporation therein, respectively, shaH afford at the expense of such township or municipal corporation public support or relief to all persons therein who are in a condition requiring it 234 Section 3480 of the General Code is more specific in regard to the character of the relief to be given by the trustees or municipal' officials: When a person in a township or municipal corporation requires public relief, or the services of a physician or surgeon, complaint thereof shall forthwith be made by a person having knowledge of the fact to the township trustees, or proper municipal officials. It is therefore clear that the township and municipal officials are not only expected to provide food and clothing for their poor, but also medical and surgical aid. Provisions for permanent relief are found in section 2544 of the General Code: In any county having an infirmary, when the trustees of a township, aft^r making the inquiry provided by law, are of opinion that the person complained of is entitled to admission to the county infirmary, they shall forthwith transmit a statement of the facts to the superintendent of the infirmary, and if it appears that such a person is legally settled in the township or has no legal settlement in this state, or that such settlement is unknown, and the superintendent of the infirmary is satisfied tna't he should become a county charge, they shall forthwith receive and provide for him in such institution, or otherwise and thereupon the liability of the township shall cease. "From the provisions of this section", says the Attorney General in a recent opinion: It is manifestly the policy of the law that in case of all those persons who are entitled to admission to the county infirmary and whose circumstances and conditions are such as to reasonably indicate the necessity of public relief for an indefinite or considerable period of time, the matter of providing relief should ; be in as expeditious a manner as is practicable and in conformity with the law be turned over to the superintendent of the county infirmary and in those cases the trustees should provide only such relief as is required to transmit to the superin- tendent of the infirmary the statement of the facts required and for such person in the course of business to be received by the superintendent. MEDICAL CARE "At present, therefore, poor persons afflicted with communicable diseases, or otherwise unable to provide for themselves temporarily, are virtually dependent on the official generosity of the township trustees or municipal officers. If they reside in some of the larger cities of the state, the chances are that they will receive good care. Cleveland, Cin- cinnati and a number of other cities have well equipped municipal hospi- tals, and in all the important centers private hospitals do a great amount of charity work. But the sick poor residing in rural districts, villages, or even in some of the fairly large towns receive little or no medical care and hospital care is out of the question. The self-respecting workman does not think of asking aid from the township trustees or officials in the smaller cities, for he feels that it 235 singles him out as a pauper; and the same is true, to a more limited extent, in the larger cities with well equipped municipal hospitals. In six of the 45 counties visited the county has come to take the place of the township in caring for the sick. Each of these counties employs a physician who attends to all cases of sickness both inside and outside the county infirmary. Serious cases are taken either to the infirmary or some private hospital. In one county every township employs a physician, half of whose salary is paid out of the county infirmary fund. In 38 of the counties included in the survey, sickness, including communicable diseases, was cared for in the county infirmaries. In the remaining cases the sick poor were sent to municipal or private hospitals. Thirty county infirmaries caring for sickness as well as com- municable diseases had practically no hospital faciHties. Not one of them employed a trained nurse, and at least half did not have a practical nurse. In many cases the sick were housed in an old outside building with iron doors, formerly used for the insane. The sanitary conditions in these buildings were simply revolting. In some cases the odor was unbearable ; the bed clothing was ragged and dirty ; old-fashioned toilets which had not been cleaned for many months were frequently found in the bedrooms. The superintendents generally admitted that these toilets were insanitary but excused themselves on the ground that the commissioners were unwilling to supply the funds .to have them removed. In such quarters, the county superintendents accept the most serious cases of sickness. Persons afflicted with communicable diseases are admitted without any provision for proper isolation. Of the 89 coimty and city infirmaries in the state, 80 expended less than $600 a year for medical care in 1916-17; 76 less than $500; 71 less than $400; 66 lesa than $300; 47 less than $200 and 11 less than $100. A physician who sets any value on his time will not be willing to give the necessary attention to an infirmary for such small amounts. During the course of the survey, complaints about the lack of med- ical care in the county infirmaries were heard on all sides and it is to be feared that many of them are amply justified. In a few cases the physi- cian's contract does not require regular visits to the county infirmary. He is supposed to come at the call of the superintendent when some inmate is seriously ill. TUBERCULOSIS AND THE INFIRMARY Section 3139 of the General Code provides that on and after Jan- uary I, 1914, "No person suffering from pulmonary tuberculosis, com- monly known as consumption, shall be kept in any county infirmary." In spite of this legal prohibition, one or more cases of tuberculosis were found in eight of the 45 infirmaries visited; and a stricter examination would in all probability have shown that twice this number of infir- 236 maries violated the state law by retaining persons suffering from this disease. Some of the superintendents claimed that they had been unable to find an institution for tuberculous cases. Others claimed that one or more cases from the county had been sent to the state tuberculosis hos- pital, but the authorities there refused to accept them. Having been refused attention for their cases, they felt that the state could not hold them responsible for violating the law. They were evidently unaware of the fact that the state tuberculosis hospital is intended for incipient cases. In order to provide for tuberculous patients who might become county charges, the state legislature in 191 1 passed a law providing that: The commissioners of any two or more counties not to exceed ten may form themselves into a joint board for the purpose of establishing and maintaining a district tuberculosis hospital, provided there is no municipal tuberculosis hospital therein for the care and treatment of persons suffering from tuberculosis. It was further specified that the tuberculosis hospital should be separate and apart from the county infirmary. Eight tuberculosis san- atoria are now operating in Ohio in conformity to the provisions of this law. Two of these are being operated by the cities of Cleveland and Cincinnati; two by single counties, Franklin and Lucas; and the other four by districts containing from two to six counties. Two counties maintain tuberculosis^ hospitals as an integral part of their county infirmaries. One of these has not been approved by the State Depart- ment of Health and therefore has no legal existence. The second has been erected since the tuberculosis law went into effect and has been approved by the State Department of Health, although it has no trained nurse or resident physician, and differs little from the ordinary county infirmary sick ward. Twenty-six of the 88 counties in Ohio care for their dependent tuberculous patients either in municipal, county or district hospitals. Of the remaining 62, some care for their tuberculous patients in the county infirmaries and others in private institutions. In at least 25 counties, dependent tuberculous patients are cared for by outdoor relief, which means an order for groceries once a week and for a little coal during the winter months. One of the greatest defects of the tuberculosis hospitals maintained by the different counties is their association with the county infirmaries. The hospitals have been erected in order to care for persons who other- wise would have to be cared for in the county or city infirmary. The working-man, who may in this emergency need the care thus provided, objects to this arrangement because it hurts his pride to associate with confirmed dependents. In seven infirmaries visited, major surgical operations had been 237 performed without any hospital facilities and in the most undesirable surroundings. These institutions had never secured the services of a trained nurse and in some cases the patients had been cared for by persons who had had no practical nursing experience. The Ohio counties will not provide medical aid except for persons who are completely dependent. A wage-earner or the members of his family when in need of medical or surgical attention cannot appeal to the county officials. A number of cases came to light in the course of this study in which physicians had appealed, without success, to the county officials on behalf of working-men who needed hospital care but were unable to pay for it. OUTDOOR RELIEF. Section 2544 of the General Code, already cited, authorizes the superintendent of the county infirmary to care for county charges in the county infirmary or otherwise. The word "otherwise" as interpreted by the Attorney General means that outdoor relief may be granted tem- porarily to persons whose physical condition does not permit their removal to the county infirmary. This interpretation makes the giving of permanent outdoor relief by the county illegal in Ohio and sanctions temporary relief only in certain extraordinary cases. Twenty-five of the 45 counties visited did not follow the Attorney General's interpretation of the word "otherwise". All these counties regularly granted permanent outdoor relief. In four counties almost as many persons were being maintained, by outdoor relief as in the county infirmary. One county expended $24,106.78 for outside relief last year, or about twice the amount expended for mothers' pensions in the same county. During the month of June, 1918, this county was caring for nearly 200 persons by outside relief. One hundred and nineteen of these cases were dependent mothers with children, most of whom should have received mothers' pensions. All relief work was done by one man, who at the same time had charge of admissions to the county infirmary. This county relief agent had so many things to attend to that he found it impossible to keep records or properly investigate applicants for relief. This, however, is not the only county in Ohio where public relief is giyen in a careless and indiscriminate manner. With possibly one ex- ception, no county provides for a careful investigation and supervision of persons receiving relief. In this respect the work of the counties is not much superior to that of the townships. The total expenditure of Ohio counties for outside relief in 1915-16 was $228,029.42, and the number of persons aided were 6,708. The amount has remained about the same during the past six years, notwith- standing the enactment of the mothers' pension law which provides for -a number of persons who otherwise . would be receiving outdoor relief. 238 The infirmary superintendents advance two arguments in favor of jtdoor relief. Some claim that it is frequently less expensive to main- in persons outside than inside the county infirmary. These superin- ndents give outdoor relief to persons who are able to care for them- ;lves, or who can find others to care for them outside of the county ifirmary. The amount given generally varies from $1.50 to $2.00 a eek. The sum of $2.00 a week may seem insufficient for an aged :rson, but the ordinary old man or woman would rather have this small nount than go to the infirmary. The second contention is lat outdoor relief tends to prevent the breaking up of home life and le separating of the aged and infirm from all that is dear to them. This is undoubtedly true. It does not follow, however, that indoor ;lief is the only alternative or that public relief of any kind is the isirable solution of the problem. Old age is the most prominent of all le factors in permanent dependency. It is a far better social policy, lerefore, to provide for the aged under a system of social insurance J means of old age pensions to which the pensioners themselves have )ntributed during their prime. It is safe to say that nearly 50 per cent of the outdoor relief in Ohio the present time goes to dependent mothers with children. The courts mnot provide adequate relief for these mothers because of the limited inds at their disposal. It is undoubtedly more desirable that the rate : taxation for mothers' pensions be increased to provide sufficient funds I that dependent mothers and their children need not be cared for from e general county fund. THE INFIRMARY POPULATION In the ordinary Ohio county infirmary those temporarily sick, the )bo, the permanently disabled by sickness or accident, the feeble- inded, the partially insane, the epileptic, the old and infirm and the iformed represent the different types to be found. A total of ,14,916 persons was cared for in the county and city firmaries in Ohio in 1916-17. Of these 1,646, or ir.02 per cent, died; [8 or 0.93 per cent, were sent to state institutions; 5,263, or 33.27 per nt, were discharged, leaving 7,869, or 54.09 per cent, in these insti- tions in September, 1917. The latter number represents the perma- int infirmary population. The 5,263 discharged inmates represent the )ating winter population composed largely of men who have never orked steadily, who have been accustomed to spending the greater part their money in drink, or in the gratification of other bad habits., uring the summer months, they are able to secure casual employment,, tiile the ofif days are generally devoted to spending their surplus earn- gs. When winter comes they have nothing left. In many cases, the Dthes which they received from the county some months before have en pawned and they must turn their faces once more to th? cQUnty 239 . infirmary. Many of these men are scarcely past middle life and are capable of doing hard work, if some means could be devised for keeping them under restraint. The county infirmary or the county jail is not the propel^ place for such persons. They should be assigned to a state penal institution where they would be compelled to do steady and con- sistent work. The county infirmaiy simply encourages them in their vicious habits by providing them with a haven of refuge during the winter months. The following table, which is a summary of the reports made by the superintendents to the Ohio Board of State Charities, distributes the regular inmates of county infirmaries according to the character of their disability. From Table I it will be seen that nearly half, or 47.6 per cent, of the regular inmates of county and city infirmaries are old and infirm and that 24.5 per cent are sick and diseased or persons who have become disabled through loss of members. More than 75 per cent of the inmates of county infirmaries in Ohio are, therefore, old and infirm, or persons disabled by sickness, disease or accident. The remaining 27.7 per cent is made up of a miscellaneous group of persons with various defects. Table I. The Number of Persons in County Infirmaries and Character of Disability Cause Per cent Insanity Epilepsy Idiocy Old age Siskness or disease Loss of memters.. Deformity Blind Deaf Maternity Not disabled Total 2.67 1.46 4.46 47.67 24.59 3.24 2.32 3.46 1.54 .27 8.33 A study of 2,260 persons representing the total population of 22 typical infirmaries in Ohio madff by the writer showed results somewhat different from the foregoing. Of the 2,260 cases 830, or 36.46 per cent, were old and infirm, 305, or 13.4 per cent, were defective mentally and i,io6,-or 49.77 per cent, suffered from disease or physical defects. The following table contains a detailed analysis of the 2,260 cases classified by age, sex and principal causes of disability. 240 Table II. Principal Causes of Disability in Certain Specified Age Periods Male Cause 16- 49 50- 59 60- 64 65- 69 70- 74 75- 79 80- 84 85- 89 90- over Un- known To- tal xidents 25 55 8 16 3 4 2 17 6 7 8 5 27 2 65 2 7 9 14 23 12 6 65 2 24 36 1 14 7 2 2 6 14 19 23 9 2 51 1 39 18 2 '? 1 5 30 9 -116 11 4 51 2 16 12 6 3 1 13 12 155 6 3 29 1 8 7 1 6 1 8 4 134 6 2 16 4 3 I 1 1 1 2 87 4 1 5 1 2 1 1 46 10 1 21 3 1 2 6 1 0' 139 isanity and feeble- mindedness 185 jilepsy 12 iralysis 129 iabetes '. . 19 jberculosis 9 ithma 17 snereal diseases 38 87 Icoholism 76 582 indness and deafness, iscellaneous diseases... iseases not stated information concern- ing physical condition. 69 25 235 8 Total 185 271 211 315 248 193 111 62 25 9 1,630 Female Cause 16- 49 50- 59 60- 64 65- 69 70- 74 75- 79 84 85- 89 90- over Un- known To- tal ;cidents isanity and feeble- mindedness )ilepsy iralysis iabetes jberculosis ithma jnereal diseases leumatism coholism ,d age indness an:! r'eafrcs'. iscellaneous disorders, seases not stated. . . . D information concern- ing physical condition Total 48 2 3 1 1 1 3 3 27 102 29 3 1 4 7 1 2 9 3 47 19 1 7 1 1 3 5 14 1 1 27 1 6 3 2 6 39 2 5 8 2 3 51 1 2 5 1 1 1 3 1 48 2 a 4 2 3 1 1 1 47 2 1 6 2 33 1 1 11 1 1 1 105 83 76 72 67 67 39 14 120 5 25 8 3 4 9 27 5 248 16 15 125 11 630 The cau.=;es of di.sability specified jre complaints rather than agnoses. The gradual breaking down of physical stamina, the reduc- Dn of vitality and the weakening of mentality in old age predispose and accentuate disorders of negligible importance in earlier life. Even ith the most careful and minute medical examinations, it is frequently most impossible to designate any particular disability as the chief. 241 The . county infirmary is evidently not the place for the feeble- minded, the blind, the deaf and the epileptic; however, the state insti- tutions for these groups are already overcrowded. Nearly all the counties have long waiting lists of applications for admission to the various state hospitals, schools and institutions for defectives ; and many of those on the waiting list must be accommodated temporarily in the infirmaries. No matter how far the capacity of the different state institutions may be increased, the county infirmaries must still care for the partially insane who cannot be very easily retained in the state hospital. Of the 2,260 infirmary inmates of whom a detailed study was made, it was possible to obtain information in regard to the most important cause of poverty in 1,608 cases. As is shown in the following table, disease, sickness, or accident was given as the most important cause of dependency in 482 or 29.9 per cent of the total number of cases ; intem- perance in 468, or 29.1 per cent; improvidence in 178, 11.09 P^"^ cent; misfortune in 187, or 11.6 per cent, and low wages in 96, or 5.9 per cent, of the total number of cases. » Table III. Principal Causes of D e pendency Principal causes Number Per cent Disease . - - - 482 178 468 187 96 107 90 29 97 Improvidence Intemperance "Misfortune 11.09 29.10 11.63 Low waffes 5.97 Insanity and Old age feeble-mindedness 6.65 5.59 Total 1,608 100.00 Among the inmates of county infirmaries are to be found some who were once prosperous; of the 1,608 studied 113 had had property valued at more than $2,000, while 39 had had property valued at more than $10,000. Of the 159 property owners from whom information was obtained, 70 had lost their property by business failure ; 61 by poor in- vestment; 17 by bad loans; two by illness and nine by improvidence. A number of business failures, however, were due either directly or indi- rectly to improvidence or intemperance. 242 Table IV. Number of Persons who report hamng had a Bank Account, Property, or Investment at any Time Value of property Number Per cent $1,000 to $2,000 124 53 21 39 52.32 Over $2,000 but less than $5 000 . ^ 23.36 $5,000 but less than $10 000 8.86 $10,000 and over 16.46 Total ^ 237 100.00 The immigrant does not figure as largely in the county infirmaries in Ohio as one might be inclined to expect. Of the 7,869 persons in the infirmaries in September, 1917, the Ohio Board of State Charities obtained reports on the nativity of 7,037. Of these 4,065, or 57.8 per cent, were born in Ohio, 1,516, or 21.5 per cent, in other states and 1,456, or 20.6 per cent, in foreign, countries. In regard to age distribution, the records of the Ohio Board of State Charities show that 4,722, or 60 per cent, of the regular infirmary inmates were over 60 years of age, 2,926, or 37.1 per cent, between 16 and 60 and 219, or 2.78 per cent, under 16 years of age. The presence of a large number of persons in an infirmary or alms- house is suggestive of abnormal family relationships. Why is it that the disabled cannot make their homes with parents, brothers, or sisters; or that the old and infirm cannot be maintained by their children ? A study of the domestic relations of 2,260 infirmary patients showed that 1,032, or 45.6 per cent, were never married. These, as a rule, had no one on whom they could depend. Their parents were dead, and brothers and sisters, even when in good circumstances, cannot be relied upon to maintain a disabled brother or sister. Of the 822 inmates who had been married, 605, or more than half, had one or more children living; of these 232 had children able to support them. The children of the remaining 373 were generally ordinary unskilled working-men with large families of their own. These could scarcely maintain their parents without depriving themselves or their children of some of the necessaries of life. Table V. Marital Condition of Infirmary Patients Studied Marital condition Number Per cent distribution Sinsfle • i 1,032 822 235 83 47 5 37 8 Widowed 10 9 Divorced or seoarated 3 8 Total 2,172 100.0 243 About 7 per cent of the inmates- studied were in the infirmaries because their children, although in fairly good circumstances, were unwilling to maintain them. In comparison with total infirmary pop- ulation, this number may seem very small, but of 232 inmates with children able to support them, only 88, or 37.9 per cent had children able and willing to support them. We are almost forced to conclude, then, that parents cannot rely upon their children in their declining years with any sense of security. The maintenance of the aged is too serious a burden for the ordinary wage-earner with a family ; but aside from the economic burden, there are other considerations which tend to under- mine the obligation of children towards their parents. Marriage brings a great change in family relationships. Married children' are frequently faced with the alternative of neglecting their parents or introducing friction into their own families. The son-in-law or the daughter-in-law may object toi the presence of the parent in the family. The aged, too, are sometimes difficult to get along with. Frequently, they labor under the impression that they should have a final say in all domestic affairs; and when they are opposed, friction and bad feeling develop. The Ohio law enforces the obligation of children to maintain their aged parents. Section 12,424 of the General Code provides : Whoever, being an adult resident of the state and possessed of or able to earn means sufficient to provide food, shelter, care, and clothing for a parent within this state, who is destitute of means of subsistence and unable either by reason of old age, infirmity, or illness to support himself, or neglects or refuses to supply such parent with the necessary shelter, food, care, and clothing shall be imprisoned in a jail or workhouse at hard labor for not less than three months or more than a year. At least half of the 45 counties visited made practically no attempt to enforce this law. In some counties, the infirmary superintendent had brought a number^ of cases to the attention of the prosecuting attorney, but nothing was done. The prosecuting attorney has found, it difficult to enforce the law in the case of wage-earners, because there is nothing to attach ; however, thei^e is no good reason why it should not be enforced against children in comfortable circumstances. MAINTENANCE COSTS Tlie superintendent of the county infirmary must make a detailed statement of costs to the county commissioners once a year on blanks supplied by the State Auditor's office. One copy of this report is lodged with the county auditor and one sent to the Bureau of Inspection and Supervision in the State Auditor's office. The accounts of the infirmaries like all public institutions are examined periodically by the State Bureau of Inspection and Supervision. In view of the close supervision exer- cised by the state over the expenditures of infirmaries, one expects to get 244 an exact statement of the cost of maintenance. This, however, is far from being the case. From the -reports of the superintendents, one can find how much has been paid for labor and services of different kinds; how much has been received from the sale of farm products; but one looks in vain for a statement of the returns from the infirmary farm or the cost of operating it. Most of the infirmaries have farms of from 200 to 500 acres. Some produce. a sufficient supply of vegetables and meat to maintain the institution for the year and have a surplus for the market. These naturally show a low per capita cost. Ten had a per capita cost of less than $100 in 1917, while some with approximately the same population and acreage had a per capita cost of $200 or more. A system of evaluating all farm products consumed in the infirmary or inarketed outside would enable one to discover exactly how much the infirmary was costing the county. Independent of the value of the farm products consumed in these institutions, the cost of maintaining the city and county infirmaries in Ohio in 1915, was $1,455,944 and the average per capita cost was $169.88. Of the 80 infirmaries reporting, 13 had a per capita cost of less than $100; 27 between $100 and $149; 20 between $150 and $200; 15 between $200 and $250; four! between $250 and $300; and one over $300. The per capita cost in the National Soldiers' Home at Da)rton for 1917 was $222.95, or less than the amount expended on each inmate by ten of the largest infirmaries in Ohio, although the standard of care in the Soldiers' Home is withoiit question 200 per cent higher than that in any infirmary in the state. For the medical care of 5,429 persons, excluding the cost of drugs and medicine, the National Soldiers' Home expended $53,652.52 in 1917, or more than double the amount expended by all the infirmaries in Ohio for their 14,916 inmates, if we except Lucas county which maintains a large hospital costing $17,000 in 1917. GENERAL CARE OF INMATES The care of the various inmates in the county and city infirmaries in Ohio is a rather difficult problem; but it is one which is not taken very seriously, as is evident from the conditions prevailing in the 45 infirm- aries visited in the course of .this study. Thirteen were in very bad condition, 19 others would not come up to any reasonable standard, and the remaining 13 were in fairly good condition. In three infirm- aries among those in bad condition, new buildings are absolutely essen- tial for any improvement in the situation, the old buildings being entirely uninhabitable. Persons employed to keep the premises clean seemed more lavish in the use of disinfectant than of soap and water. The inside of the buildings was unclean and slovenly; the walls had not been painted in a generation and no attempt had been made to repair cracks or other effacemepts. 245 Many old persons suffer from foul smelling disorders and when a number of them congregate in small groups, the resulting bad odor is very noticeable to a person unaccustomed to it. Lack of attention regarding personal cleanliness, poor ventilation and over-heating tend to accentuate the odor. In many of the buildings inspected, sections occupied by the inmates were so foul smelling that they were almost unbearable. The inmates frequently were unclean, the beds dirty, the bed covers old and worn and ventilation poor. Those who were unable to care for their physical needs demanding constant attention, had to depend on other inmates for the most urgent wants. Often, these improvised attendants were feeble-minded or at least ignorant and inat- tentive. In the entire group there was virtually no medical supervision. Of course, the infirmary superintendents are not always responsible for this lack of care. They are naturally victims of their own limitations and of the system under which they live. As a rule, they have had no experience in the work preceding .their appointment, and they cannot make a single improvement without consulting the county commis- sioners. The 19 infirmaries classed as not coming up to any reasonable -standard were much better than the foregoing. Most of them had fairly good buildings and, in most instances, an attempt had been made to keep the buildings, the toilets and sleeping quarters clean and neat. Only one of these institutions made any attempt to separate the inmates by groups. Usually the old people who had been compelled to go to the infirmary through no fault of their own, had to sleep in the same dormitory and eat at the same tables with the feeble-minded and the partially insane. In three of the 45 infirmaries studied, an attempt was made to segregate the partially insane, but the quarters set aside for them were most undesirable. They were housed in cells and rooms by no means san- itary, and were never given an opportunity for exercise or recreation. The superintendents claimed that if such persons were permitted to move around freely, they might interfere with the happiness of other inmates or run away. The writer suggested that the superintendents might follow the example of the National Soldiers' Home at Dayton by erecting a high wire fence around the building intended for the insane and feeble-minded. This would prevent them from running away or interfering with others ; at the same time it would give them an oppor- tunity of enjoying the fresh air and the sunlight. The general reply was that it would cost too much. Only two of the infirmaries suppHed medical care worthy of the name, and in these two the inmates were neglected in other respects. One had a number of attendants who were very harsh and cruel in their treatment of the inmates. All of the 32 infirmaries accepted hospital cases and had major surgical operations performed without any hospital facilities. In a number of these, such contagious cases as were treated, were not properly isolated. 246 In the 13 infirmaries which were doing fairly good work one found an approach to the standards of the private homes for the aged. The buildings werei in good condition and cleanliness seemed to be a matter of course. Five or six institutions had a genuine homelike spirit. In all, the bedrooms were neat and well ventilated. Instead of the old straight back chairs, one found rocking-chairs in the recreation room. In the dining room, chairs had taken the place of the old-fashioned benches. Most of the infirmaries provided care for the sick outside of the institution in public or private hospitals. RECOMMENDATIONS Even with their present equipment and with very little additional expense, most of the infirmaries in Ohio could provide reasonable standards for the care of the inmates. I. It does not cost very much to paint the inside of the building every four or five years, but it adds very much to the general appearance. II. It means additional labor to keep the toilets, the bedrooms, the bathrooms and the persons of the inmates cleah and neat but it will improve their general health and comfort. III. Old, torn and ragged bed linen and covers should not) be tol- erated in any public institution. The old straw mattresses remind one of the English poprhouse of 50 years ago. One does not find a straw mattress in private institutions for the sick or aged, yet its use it quite common in the county and city infirmaries. IV. Common sense dictates that no person should be admitted to the infirmary without a medical examination. Experience shows that a medical examination is a necessary safeguard both for the prospective inmate and the institution. It is enforced in the Soldiers' Home and in any up-to-date institution for the aged. A record of the examination should be retained for future use. V. The infirmary physician should visit the institution regularly at least once a week, and, of course, more frequently when there are serious cases of sickness. He should have regular office hours on his visiting day so that any inmate who desires may have a chance to consult him professionally. It is certainly a wrong policy to discourage frequent visits to the physician on the ground that it leads to a waste of medicine. It is an equally wrong policy to have the superintendent take over the greater part of the medical care himself and administer remedies for all kinds of ailments, in order to save expense. VI. A number of county officials in Ohio favor an amendment of the tuberculosis law to pefmit county infirmaries to care for advanced tuberculous cases. Nothing could be more harmful. While a few in- firmaries might make proper provision for these cases, the majority would allow them to mingle freely with the other inmates. Some in- 247 firmaries are doing this at the present time in violation of the state law. The infirmaries have no facilities for treating tuberculous patients and should not be permitted to do so. VII. -The diet of the 45 infirmaries visited, wiljh six exceptions, seemed to be more influenced by economy than the welfare of the inmates. In some, meat three times a week was the rule, and considering the quality of the meat served this was quite sufficient/ Not every con- stitution, much less that of an aged and infirm person, can stand pork or red meat three times a week, the year around. The diet problem in the infirmary might be simplified if the superintendent followed the directions of a competent and experienced physician. VIII. "If I could keep these old folks busy half of my difficulties would be solved, they would have no time for nurturing grievances, or for criticism, and would be a happy and contented bunch." In this simple way, an infirmary superintendent of long experience gave ex- pression to his thought on one of the most important problems in a county infirmary. He did not try to get all the inmates to work on the farm as so frequently happens in other infirmaries. He had secured all the information he could about the previous training and experience of each inmate. Some had been machine hands of dififerent kinds, and for these, he improvised a machine shop. For another group, he opened a blacksmith's shop and for a third, a carpenter's shop. These shops, he claimed, had saved him over $2,000 in repairs during the past year and in addition, the inmates turned out many articles which they marketed themselves. The example of this infirmary superintendent shows what might and can be done in all county and city infirmaries in the state if we had superintendents with vision. IX. Heart trouble and shortness of breath frequently accompany old age, and the infirm and the aged should not be compelled to climb high stairs as so generally happens in the present county infirmaries. Some infirmaries try to solve this problem by housing the infirm in rooms or wards up-stairs where they never have a chance of getting out into the fresh air. The installation of an elevator does not cost very much, but no county infirmary visited seemed to have realized its benefits. X. A number of counties in Ohio must erect new buildings before they can expect to give the decent and humane treatment the aged rieceive in the ordinary private institutions. It would be most advisable if those counties, which must erect infirmaries in the near future, could get together in groups of two or three and build joint institutions. The taxpayers of the counties could easily be convinced that this would mean a considerable saving for them ; and also give them an institution of which they could feel proud. At the present time, the counties are cooperating in the erection of tuberculosis hospitals; are permitted to cooperate in the erection and maintenance of children's homes and in one 248 case have availed themselves of this permission. There is then no good reason why they should not be permitted to cooperate in the erection and maintenance of county infirmaries. XI. In no respect does the weakness of the present county infirmary system become more apparent than in the matter of providing medical aid for the sick. Proper medical and hospital facilities cannot be pro- vided in the ordinary county infirmary without expenditures entirely out of proportion to the number^ of persons treated. It certainly is not good economy for one county to expend $30,000 to $50,000 in providing hospital care for 30 people, when by acting in conjunction with two or three other counties, the same care could be secured for half of the amount. If the hospital is operated in conjunction with the county infirmary, the cost of caring for the sick will be less, but the ordinary wage-earner may not be so much inclined to partake of its benefits as if it were operated as a separate institution. It should be necessary for the counties to secure the express approval from the Ohio Board of State Charities before entering into any agreement regarding the erection of county infirmaries or hospitals. The building plans should be approved by the board also. XII. At the present time three state boards or commissions ex- ercise jurisdiction over county infirmaries; namely, the State Depart- ment of Health, the Industrial Commission and the Ohio Board of State Charities. The State Department of Health has jurisdiction in all matters relating to health and in this respect its powers are rather extensive. If conditions injurious to health are discovered by this department, it may order changes considered necessary under the circumstances and the local authorities are bound to execute this order, no matter what the cost. If the change involves an expenditure of more than $10,000, it will not be necessary to submit it to the people as is the case with changes ordered by other state departments. The Industrial Commission exercises jurisdiction over all county in- firmaries in matters relating to safety and fire prevention. Recently, it ordered an infirmary closed; but so far, the voters of the county have refused to sanction the floating of a bond issue for a new building. The powers exercised by the Board of State Charities over county infirmaries are merely advisory. The board is supposed to approve plans for the erection of new buildings, but in this, as well as in other matters, the county officials are not bound to follow directions. The board should exercise the same powers over county infirmaries which it exercises over children's homes, and should formulate standards for all infirmaries. Any institution which fails to live up to the established standards, should be forbidden to accept charges ; and the board should be empowered to care for the poor of that county in other institutions at the expense of the county. 249 The Board of State Charities could enforce its standards far more effectively, if able to offer positive inducement to the institutions to live up to them. In Massachusetts, the state will not contribute to the sup- port of non-residents in almshouses unapproved by the state board of charities ; Pennsylvania contributes a certain amount per capita towards the maintenance of persons committed to county jails on condition that they conform to standards formulated by the board of state charities and Wisconsin contributes towards the maintenance of the insane in county institutions on the same condition. XIII. As has already been noted, a large number of those who find their way to the county infirmary in the winter time are men who have never learned to do steady work. They belong to what is known as the "hobo" type. The county infirmary and the county jail offer pos- itive inducements to these men to continue their present manner of living. A state farm where they might be compelled to engage in useful work for a period sufficiently long to enable them to overcome their present careless habits, is the only effective means of dealing with such persons. XIV. Many of the difficulties which arise in the administration of county relief are due to the lack of uniformity in the methods adopted by different officials. There are as many persons giving outside relief in the county as there are township officials and each follows his own method. In regard to the meaning of temporary and permanent relief, there seems to be an unending conflict of opinion between the township officials and the superintendent of the county infirmary. The same lack of uniformity which is so evident iii the administration of county relief is also found in the administration of county health. This situation could be remedied by making the county the unit for the administration both of health and of relief. On account of their close relation to one another, health and poor relief in the county should be in charge of one man. This same person might also be charged with the care of dependent children. He should, in fact, be charged with the administration of all county social problems and might appropriately be called the County Welfare Director. The County Welfare Director should be appointed by and should work under an ex-officio board of present county officials, or a board elected for the specific purpose. XV. It is difficult to make a statement in regard to the number of persons in county infirmaries in Ohio, who might qualify for or profit by an old age pension. Nearly all the women inmates are in the in- firmaries through no fault of their own and could be trusted to turn a pension to the best account. With the present infirmary standards, women who need constant medical attention, would be much better off if cared for in the homes of their children or friends, with a pension of three dollars ($3.00) a week. 250 At a conservative estimate, not more than 25 per cent of the men in county infirmaries in Ohio at the present time would qualify for or profit by a pension. The other 25 per cent are weak mentally, are dis- abled by sickness or accident, or have been the victims of vicious habits throughout their lives. These would profit more by a higher standard of institutional care than by a pension. CHAPTER XVIII THE AGED IN PRIVATE INSTITUTIONS Dr. John O'Geady In order to obtain a clearer idea of the kind of care . provided for the aged, a study was made of the private institutions receiving such patients. In June, 1917, there were approximately 46 private institutions for the aged and infirm in Ohio, caring for 2,628 persons. Of these, six had less than 10 inmates each, 20 had less than 25 inmates each, 29 had less than 50 inmates each, eight had between 50 and 100 inmates each, and nine had over 100 inmates each. The total amount expended for the care of the aged and infirm in these homes in 1917 was approximately $800,000. The property value of the homes amounted to $4,500,000. No report is made to the Board of State Charities or to any other state agency concerning the conduct of these private homes for the aged ; no inspection of physical conditions is made nor is a statement as to the number or social status of inmates required. Fourteen of the private institutions for the aged in Ohio are owned and controlled by churches, four by national groups, three by fraternal orders, and the remaining by individuals or associations interested in the care of the aged. Of the 46 private institutions for the aged 28 having a population of 2,050 were visited. Of these, 11 were maintained by associations established for this particular purpose ; 10 were maintained by direct appeals to public charity, four were endowed and three were supported by the members of fraternal orders. With six exceptions, the 21 homes maintained by associations or by public charity had the greatest difficulty in meeting their obligations. Sixteen o'f the 46 homes are intended exclusively for women, the remainder admit both men and women. Six require membership in a particular religious organization; seven are confined to persons of a particular race or nationality and three are intended exclusively for the members of three fraternal orders. The remaining 30 make no dis- tinction of race, religion or nationality. Nineteen institutions charge no admission fee and are intended primarily for persons who have no other means of support. The dependent poor are generally given pref- (251) 2^2 erence in these institutions, but many homes including the seven largest will not admit persons who have children able to maintain them, or who have other visible means of support. Nearly all the private institutions for the aged in Ohio require persons seeking admission to be at least 60 years of age and demand a certificate of good conduct from all applicants. This enables them to exclude the hobo and other unde- sirables. Only four, intended primarily for invalids, admit persons needing hospital care. Six of the 28 private institutions visited required applicants for admission to undergo a medical examination before ad- mission. Only six were visited daily by a physician. In the other in- stitutions a physician was called when any of the inmates was seriously ill. Only three institutions employed a trained nurse. All persons admitted are placed on probation for a period of six months ; if at the end of this period they are dissatisfied, their admission fee is returned, less the cost of board. From 12 institutions visited it was possible to secure information in regard to the ages, date of admission, nativity, savings in early life, causes of loss of savings and principal factors in the dependency of the inmates. These 12 institutions which ma)' ba regarded as fairly typical cared for 525 persons. The following table shows the age distribution of the persons studied : Age Distribution of 525 Persons in Private Institutions for the Aged Age period Number Per cent Under 60 30 47 80 112 120 134 2 5.7 60 to 64 8 9 65 to 69 15.8 70 to 74 21 8 75 to 79 22 9 80 and over 25 5 Unknown . 4 Total 525 100 Of these 525 persons studied who are typical of the inmates in pri- vate homes, 69.7 per cent were 70 years of age or over. ^53 The following table shows the age at which the 525 persons studied entered the institutions: Age at Entry of Inmates in Twelve Private Institutes for the Aged Age Number Per cent Under 60.. . 38 50 92 134 106 105 7.2 60 to 64 9.5 65 to 69 17.5 70 to 74 . . . 25.5 75 to 79 20.2 20.1 Total 525 100.0 Thus, 345 or 65.8 per cent of the persons cared for in 12 institutions entered after they were 70 years of age. This accords with the view so frequently expressed by those in charge of such institutions. For the aged and infirm, the institution is always the last resort. The old man after he has given up work tries to live on his small savings for a few years, and when they are all but exhausted he seeks admission to an old folks' home. The aged woman struggles on after her husband's death. She may have had a little property left her, but, unaccustomed to busi- ness dealings during her husband's lifetime, she may not make the best use of it, and in the end is cornpelled, to seek refuge in a private insti- tution for the aged. Information was obtained in regard to the domestic relations. One hundred and sixty-six were married; 177 were widowed and eight were separated or divorced. One himdred and seventy-five had children living and of these, yy had children who were in a position to maintain them. Only 43 aged persons had children who were actually contribut- ing to their maintenance. Of 98 persons who at some time had had savings amounting to $2,000 or more, 40 claimed to have lost their savings by business failure ; 18, by poor investment; and 13, by loaning money to children or friends, while 17 had retained their savings and handed them over to the insti- tution. Of the 525 cases studied, 500 were dependent either on children or on the institution; 17 had saved sufficient to maintain them and eight were receiving a soldier's pension. 254 The following table shows the principal causes of dependency in the order of their importance in the above 500 cases : Principal Causes of Dependency among the Inmates 0] Institutions for the Aged ' Twelve Private Principal causes Number Per cent Disease and sickness 204 98 60 59 50 29 40.8 Misfortune 19.6 Intemperance 12.0 Low wages 11.8 Improvidence 10 Unknown 5 8 Total 500 100 From the table it will be seen that disease and sickness are by far the most important factors in the dependency of the inmates of private institutions for the aged. "Was sick for two or three years and lost all I had", was a frequent complaint of the persons interviewed in the private institutions for the aged. Twenty homes charge no fee for admission, four charge from $100 to $300; 18 from $300 to $500; two over $500 and two did not report. The homes requiring an admission fee make no distinction between the dependent and those having sufficient means. They will admit any person of good character who is able to pay the necessary fee, regardless of the extent of his means, on condition that all money or property over and above the amount necessary for admission must be placed under the custody of the institution. The inmates receive rent, or interest from the property or money during their lifetime, but after death the property reverts to the institution. A genuine attempt was made to give the inmates a quality of food suited to their condition. Meat was served about once a day, while the rest of the diet consisted chiefly of milk, cereals and vegetables. In the institutions visited, those in charge paid considerable atten- tion to cleanliness. The inmates' quarters were, generally speaking, very clean. Adequate bathing facilities were provided and all persons in the institutions were compelled to bathe regularly. In the recreation room provision was made for such games as checkers and cards. In all cases rocking-chairs were provided for the inmates, instead of benches and straight back chairs, so frequently found in the county infirmaries. Even in large institutions accommodating over 200 persons, there was a geunine homelike spirit, and everything possible was done to develop this spirit. Those in charge of the institutions seemed to take an active interest in the welfare of the old people, and to do everything - 255 possible to satisfy their wants. As a rule, the old people were well satisfied with the treatment they received. More than 50 per cent of the persons in the private old folks' homes are much better cared for than they could possibly be in their own homes, or the homes of their children. Those who were compelled to enter these institutions because their means had been exhausted by previous sickness, need constant care and attention such as could not be provided outside of an institution under any pension ulan. Those whose poverty is due to intemperance could scarcely be expected to make the best use of a pension. Of the i-emainder, the greater number would, in all probability, decide to remain in the institution even though the state should provide them with an old age pension. CHAPTER XIX THE PRESENT STATUS OF THE AGED AGE STATISTICS When the care of the aged is discussed information is naturally desired upon the extent of old age, the way in which it is now provided for and the extent to which aged people are dependent. "The following table shows the number of persons 65 and over in Ohio at stated times: Number of Persons 65 Years of Age and Over: Ohio, 1880 to 1918 Year . Total population^- Population 65 years of age and over Number Per cent 1880 3,198,062 3,672,329 4,157,545 4,767,121 5,285,000 129,080 177,154 209,563 261,810 304,137 4.0 1890 4.8 1900 .'. 5.0 1910 5.5 1918 . : 5.8 ^Thirteenth Census of the United States, 1910, Vol. I, "Population," 'Table 10, p. 30. "" Estimated. It will be observed from the above figures that the proportion of persons 65 and over has increased from 4.0 per cent in 1880 to 5.8 per cent in 1918. Estimates for future years on the basis of past rates of increase indicate that by 1920 the number of persons 65 and over will be 314,718 and that by 1925 there will be 341,173. The proportion of people 65 and over in Ohio is larger than for the United States, the percentage for the country as a whole in 1910 being 4.3 per cent as against 5.5 per cent for Ohio. If the age of 70 is taken as a guide, in 1910 in Ohio there were 151,107 persons 70 years of age and over, or 3.2 per cent of the total population. The number in 1918 is estimated at 169,000. In 1910 the number of persons 65 and over in Ohio were divided by sex as follows: males, 129,598; females, 132,212. Among those 70 years of' age and over in 1910 in Ohio there were 73,751 males and (256) 257 77i3S6 females. The following table presents the martial condition for 1910 of persons in Ohio 65 years of age and over. Marital Condition of Persons 6$ Years of Age and over, by Sex: Ohio, igio' Marital condition Males Females 7,784 84,126 36,476 1,005 8,361 46,968 Widowed 75,696 Divorced . . . 568 "^ Thirteenth Census of the United States, 1910, Vol. I, "Population," Table 82, p. 564. Among those 65 and over, there were in 1910, 70,586 who were foreign-born, or 26.9 per cent of the total 65 and over. Of the foreign- born 35,600 were men and 34,986 were women. ^ There were 2,777 negro males and 2,260 negro females 65 and over in 1910, or a total of 5,037. FOREIGN-BORN AND ALIENS Figures are not available to show what part of the foreign-born population 65 and over consists of aliens, but in 1910, 36.9 per cent of all the foreign-born over 21 were not naturalized, 5.7 per cent had taken out their first papers and 11. 2 per cent did not report. The percentage of unnaturalized persons among those 65 and over would, of course, be much smaller, because a large part of the foreign-born in 1910 were very recent immigrants. The foreigners in Ohio in 19TO had arrived as follows:* Between 1906 and 1910 129,799 Between 1901 and 1905 88,737 Between 1896 and 1900 34,501 Between 1891 and 1895 39,334 Before 1890 248,751 Not reported 57,252 Undoubtedly, the great bulk of the foreigners 65 and over arrived in this country prior to 1910. URBAN AND RURAL Persons 65 and over were distributed as between urban and rural communities in 1910, as follows; urban 114,836; rural, 146,974. In the urban communities only 4.3 per cent of the population was 65 and over while in the rural communities 7.0 per cent was 65 and ' Thirteenth Census of the United States, 1910, Vol. I, "Population," Table 28, p. 1,078. 'Ibid., Table 3, p. 1,019. 17 258 over. Thus, while the urban population numbered 55.9 per cent of the entire population, the number of persons 65 and over in urban com- munities numbered only 43,8 per cent of the total population 65 and over. The migration from state to state is shown by the census of 1910. In that year there were living in Ohio 3,546,991 people, 85.4 per cent of the total population, who were born in Ohio and 607,352 or 14.6 per cent of the entire population who were born in other states. ° There were at the same time 1,166,018 persons living in other states who were born in Ohio.' ECONOMIC STATISTICS There are numerous facts which indicate the economic conditions of the people of Ohio but few statistics show the actual economic con- dition of persons 65 and over. In 1910, there were 1,138,165 homes in Ohio, of which 264,165 were farm homes and 874,000 were other homes. The farm homes were 23.2 per cent of the total, whereas in 1900 farm homes were 29.7 per cent of the total and in 1890, 32.6 per cent of the total. Of the farm homes, 189,266 were owned in 1910, 74,465 were rented and 434 unknown. Of the farm homes owned, 135,871 were free from encumbrance, 52,382 were encumbered and 1,013 were unknown.'' Of the other homes, 384,819 were owned, 471,054 rented and 18,127 unknown. Of the other homes owned, 247,475 were free. 131,301 encumbered and 6,043 un- known.' Home ownership in 1910 was more prevalent in Ohio than in the country as a whole, the percentage of homes owned being 51.2 per cent in Ohio and 45.8 per cent in the United States as i. whole. How- ever, the proportion of homes owned has decreased in Ohio, the figures for 1900 and 1890 being 52.4 per cent and 54.3 per cent respectively, the per cent owned free being 34.6 per cent in 1910, 35.6 per cent in 1900 and 38.6 per cent in 1890, In Ohio the percentage of farm homes owned has slightly decreased. In 1910, 71.8^ per cent were owned while in 1900, 72.6 per cent were owned. On the other hand, 45.0 per cent of the other homes were owned in 1910, as against 43.8 per cent in 1900. In Ohio the number of farm homes owned free increased from 51.0 per cent of the total number of farm homes in 1900 to 51.8 per cent in 1910, and the other homes owned free decreased from 56.2 per cent to 55.0 per cent of the total. 'Thirteenth Census of the United States, 1910, Vol. I, "Population," Table 24, p. 714. ' Ibid., Table 42, p. 763. ' Thirteenth Census of the United States, 1910, Vol, I, "Population,"' Table 6, p. 1,300. ■ Ibid.., Table 10, p. 1,306. 259 The census of 1910 further classified farmers by age and by home ownership with the following result for farmers 65 and over in Ohio: Ownership Number Total farmers 65 years of age and over Farms owned free from encumbrances. Farms mortgaged ■ Part owners Share tenants Cash tenants Unknown 32,007 24,406 3,860 1,506 1,166 958 111 The total number of persons 65 and over classified as rural in 1910 was 146,974. Of these 32,007 were classified as farm operators, leaving a total of 114,967 persons 65 and over who are not so classified. The corresponding figures for 1900 were: Ownership Number Farmers 65 years of age and over Owned free Mortgaged Hired Unknown 40,984 30,585 6,359 2,874 203 In 1900 the figures were compiled giving home ownership for all persons 65 and over. The result showed that 86,656 persons 65 and over owned their own homes. The number of persons 65 and over was 209,563. Thus, 41.3 per cent owned their own homes in 1900, but of this number 13,487 homes were encumbered, or 6.4 per cent of the total. If the same proportion holds true for 1918, then out of a total of 304,137 persons 65 years of age and over 125,608 would be found to be home owners, and 19,464 of these owners would have encumbrances. It appears, however, that home ownership among persons 65 and over has materially decreased as evidenced by the decrease in ownership of farm homes indicated above. SAVINGS The postal savings bank showed, in 1917, a total of 39,347 depositors for Ohio and total deposits of $8,943,607, or $227.32 for each depositor. The amount of savings deposits in state banks, June 30, 1917, was $410,148,309 and in private banks $3, 812,076. Oii the same date there was on time deposit in national banks $110,627,000, a large part of which could be classified as savings deposits, making a grand total of 26o nearly $525,000,000, or about $100 per capita. The actual number of depositors for 1917 is not available. Building ■ and loan deposits of June 30, 1917, were $99,955,368. The amount of running stock was $135,796,709, and the amount of paid- up stock was $44,530,223. The number of depositors was 261,508, the number of stockholders 485,592 and the number of borrowers t88,334. . PRESENT METHODS OF SUPPORT Aged people who are unable to support themselves are maintained at present : By relatives and friends. By private benevolence. By private homes, church homes and society or lodge homes. By state institutions. By county infirmaries. By outdoor relief. There are 89 public infirmaries which provided for 14,916 individu- als in 1916-17. Of the inmates, 60 per cent were over 60 years of age. The number of people aided in outdoor relief in 1915 was 48,005 and in 1916, it was 28,445. Of these probably 7 to 10 per cent were aged and infirm. The total expenditure for poor relief by cities, counties and townships was $1,966,352 in 1916. Other state institutions cared for 37,139 different persons in the year ending June 30, 1917. Nearly half of these persons were over 60 years of age. During the same year ex- penditure on these institutions was $5,247,327. In addition 46 private, church and society homes were caring for 2,628 aged persons in June, 1917. The number of aged persons aided by private families or by relatives and friends is unknown and cannot be estimated. The Hamilton and Cincinnati surveys indicated that 15 to 25 per cent of pepole over 50 were dependent upon relatives or friends. Nor can the number who are living an independent but precarious exist- ence be accurately estimated. The state has an investement of over $25,000,000 in its state insti- tutions. The cities and counties have an investment of $10,000,000 in the county and city infirmaries alone. Altogether, this public invest- ment calls for an interest charge of nearly two millions annually, to say nothing of depreciation. Roughly speaking, then, nearly $10,000,000 is expended annually by local and state public charities and a large part of this, probably about half, is for the care of the aged. The amount expended by private organized charities for the care of the aged and for all relief and social work amounts to several million dollars annually. 26l PENSIONS The total number of federal pensioners June 30, 1917, in Ohio was 63,703, and the total payment to these pensioners was $15,243,996. Prac- tically all of the pensioners were over 65 years of age. The state of Ohio provides pensions for blind persons paid from the county treasuries. In 1916, 4,338 persons were pensioned at a cost of 405,077- Mothers' pensions are also paid out of the county treasuries to worthy mothers having small children dependent upon them for support. In 1916, 4,500 mothers were pensioned at a cost of $493,781. A few of the labor organizations provide pension systems, notably the Brotherhood of Locomotive Engineers and the International Typo- graphical Union. A very few local unions provide for the care of their aged members. Church organizations, including the following, also provide pension systems for their ministers : Presbyterian, Methodist Episcopal, Baptist, Disciples, Lutheran, Methodist Episcopal South and the Con- gregational. Other denominations provide in one way or another for the care of aged and superannuated ministers. Pensions for employees are provided by a number of railroads and private organizations. Railroads which have Ohio pensioners are the Baltimore and Ohio, Nickel Plate, Pennsylvania and Chesepeake and Ohio. The B. F. Goodrich Company of Akron, Proctor and Gamble of Cincinnati and the Columbus Railway and Light Company are among the industrial plants which have pension systems. Companies outside the state which have some pensionable workers in Ohio include the International Harvester Company, the Pullman Company, Western Union, American Telephone and Telegraph Company and the United States Steel Corporation. Nine cities in Ohio have teachers' pension funds, optional until January i, 1912, for teachers appointed before 1910, but compulsory for all new appointees. Every city in Ohio which has a paid fire or police department may pension its firemen and policemen. A tax levy is provided and the local pension boards may also require payment of dues from the members. We estimate that, exclusive of federal and state pensions, 3000 persons in Ohio are pensioned under the various plans. CHAPTER XX OLD AGE ASSURANCE It is apaprent from the studies in the foregoing chapters and from the testimony before the Commission that there is a- large amount of old age dependency which does not manifest itself by application for charitable relief but that many aged persons continue a precarious exist- ence in semi-dependency. It is apparent also that a great number of persons are dependent upon institutions and upon relief without having been directly to blame for the misfortunes which have overwhelmed them. The fact that a large proportion'of dependent aged are widows is sufficient proof of this statement. That 29.9 per cent of the dependency among aged inmates of county infirmaries and 40.8 per cent among those in private old folks' homes was due to sickness; and that ii.i per cent of the dependency among the aged in county infirmaries and 17.6 per cent among those in private old folks' homes was due to business failures and similar misfortunes, is proof, sufficient in itself, that the uncertainties of old age are too great for the individual to provide for alone. THE HAZARDS In the course of a normal life, untouched by serious misfortunes, a man may, even from meager income, put aside an amount sufficient to take care of himself and his wife after their producing power has gone, provided that neither he nor his wife live an unusually long time. An unusually prudent person may even provide from small income a compe- tence for old age. But to argue that all persons may do so or even that the majority may do so, ignores the hazards of life as well as the inequalities in the abilities of men to acquire and to. care for property. It also assumes that every man has been able to secure a living wage during his working life, including an amount over and above the im- mediate necessities, sufficient for old age protection. It also assumes that safe facilities are provided for investment and insurance. The hazards of life, the inequalities of men and the absence of a living wage, including insurance, are ever present factors and cannot be ignored. The presence of any one of these factors is sufficient to make a it certain that many will not be able to provide against old age de- pendency. The presence of all three factors renders the task hopeless to thousands. Sickness, unemployment, fraud, business failure, mis- fortune, lack of business judgment and an insufficient wage are all (262) 363 serious hazards which people must avoid if they are to reach the haven of economic independence in old age. The uncertainty of these hazards and the uncertainty of attaining old age itself are the real factors and are the real reasons why the insurance principle "should be applied. When a man begins his working life at, say 20 years of age, he has before him an indefinite number of years. According to the United States Life Tables half of the men who reach 20 will reach 65 years of age ; of those who reach 65, half will live to be 75 ; of those who reach 75, half will live to be 81, and of those who reach 81, half will live to be 85. In addition, the individual has the risk of disability. Each year a number of persons are incapacitated by disease or accident for earn- ing their living. At 45 very few are free from some more or less serious physical defect and by 50 the amount of annual disability suffered, in- creases to a serious extent. About this time in life the irregularity of employment grows more serious. The man past 50 is the last to be taken on and the first to be laid off. Some establishments do not hire men past 50, while others begin to eliminate old men at about that age. Coupled with all of this is the hazard of family sickness and disability and the fluctuation of business affairs. If, up to the time he has reached 50, the wage has been sufficient merely to provide for immediate ne- cessities, it has been impossible to lay aside for old age. Almost the only resource which the worker has is his children and in many cases, the children, working under similar conditions, are unable to spare enough from the necessities of their own families to support the parents without serious hardships and further handicaps. As the result of this whole precarious process, few people reach old age with a competence; a goodly number have small means; a large number have children upon whom they can rely ; while the largest group of all have practically nothing in the way of property and no children to whom they can turn, except by imposing serious handicaps upon themselves or their families. Aside from the fear of sickness or disability, therei is the dread of destitution and dependence, — those specters which haunt the lives of far more than they actually touch. Few are beyond the danger of old age dependency. Important hazards are in the path and no one knows what is in store for him. This has been brought out clearly by W. L. Mackenzie King in his book, "Industry and Humanity." There is legitimate fear where age is confronted with the alternative of poverty or dependence. Such is the case where the stress of competition drives the weak and infirm to the wall; where employers, because of compensation laws and the risks of industry, refuse employment to men of years; where increasing cost of living and diminished earnings make adequate provision for age impossible apart from constant employment.' 'W. L, Mackenzie King, Industry and Humanity, p. 383, a64 Old age pensions are based, says the same author, . . . Not on the theory that the statq owes every man a living, but rather on the fact that the provision of an assured competence for old age is an easy matter for some, whilst, ' for others, it is most difficult, if not wholly impossible. After all allowance has been made for superior thrift, intelligence, and integrity, it must be admitted that to the man who has capital to begin with, or whom* society permits to own and control vast natural resources, there are opportunities of saving not possible to the worker who possesses no capital, and who has to face uncertainties of employment and contend, unaided, against all kinds of vicissitudes. It is obvious that existing forces of world competition operate to rob advanced years, of opportunities of employment, which, under the less stren- uous regime of earlier times, were available to the close of life. There is need for society to assist in the protection of its members against a condition which simultaneously places burdens upon the worker whose day's work is done, and on the worker whose day's work is just beginning. If the young are to be given a fair start in life, the care of the aged should not be their first responsibility. If life-long public service in industry is to receive its fitting reward, years that are denied opportunity of employment should not be subjected to the humiliation of dependence or charity.' THE INSURANCE PRINCIPLE It is to these conditions that it is proposed to apply the insurance principle so that the risks and uncertainties which attend old age may be at least! partially removed by the creation of a fund from which the minimum of subsistence may be supplied aged persons without the stigma of charity. The principles of insurance are applicable to the contingency of old age in the same way as to any of the other contingencies to which they are applied. The length of life before an individual is uncertain but for a group the number who will live beyond 60 or 65 years may be accur- ately determined. The amount of money required to pay a definite monthly amount to every person over a certain age, therefore, can be estimated with reasonable exactness. These are the underlying condi- tions for insurance. Taking a group of 100,000 people who are living at any given time, we know how many under existing conditions will be alive at each successive period. If 100,000 people joined in an old age insurance plan and paid regular assessments, those who lived to be) more than 60 or 65, would be entitled to a definite payment so long as they lived. By sharing the burden of old age, all of the 100,000 people make sure that those who live beyond 60 or 65 will have a definite income. The same principle applied to all the citizens of a state would insure the citizens who may live beyond a certain age support in their old age. The principle is the same when all of the people represented in a state agree to tax themselves in order that those who live beyond a specified age may be certain of an income upon which to live. It may be argued by some that if an adequate living wage is paid, the worker will provide for his old age. What has been said regarding ^W, L. Mackenzie King, Industry and Humanity, p. 348. 265 health insurance and the living wage applies here.' Old age dependency is not strictly correlated with wages or income, for the thrifty may be pulled down by misfortune and the shiftless may get by through pure luck. The point which should be kept clearly in mind is that there are hazards of loss of health or property and the hazard of a long life after earning capacity has gone — hazards which the individual cannot measure for himself but A\hich the community or the state can measure for large groups. In this the problem resembles that of fire insurance. It may be argued that a man could lay aside every year a certain amount to create a fund to replace his losses from fire; No one does that, however, be- cause of the uncertainty of the risk. Similarly the risk of disability and dependent old age for the isolated person is not measurable and the suggestion that an individual carry his own risk is equally impracticable. The living wage must be supplemented by a social insurance program if the income is to be sufficient to provide for present necessities as well as for the contingencies of sickness, unemployment and old age. METHODS OF APPLYING THE INSURANCE PRINCIPLE Various methods of applying the insurance principle to the hazards of old age have been developed, such as old age insurance, annuities, pensions payable out of the public treasury and pensions for public em- ployees. Since these are frequently referred to by the single term old age insurance or old age pensions, it is desirable to define the terms used in this report. The term annuities is used to include guaranteed payments made from a fund which persons voluntarily create by periodic payments in the foi-m of premiums or by placing a lump sum in the annuity fund. Thus a person having $3,000 may buy an annuity which will guarantee a certain sum annually whether he lives five years or 30 years, or by annual or other payments, an annuity may be purchased which guaran- tees a certain annual income. Old age insurance is used to refer to plans whereby workers periodi- cally set aside small sums as required by law, supplemented by contri- butions from employers or the state or both. From the amount thus accumulated, aged workers who have contributed receive regularly a small stipend. An old age pension is a definite payment from the public treasury to every person satisfying specified conditions who has reached a certain age (usually 65) and who has not an income sufficient for his support. Pensions for public employees are payments made on account of service rendered in the schools, the fire department, police department, military service, etc. These may be paid entirely from the public treasury, from funds contributed by the public employees or by the employees plus a grant from the public treasury. = See Chapter VIII. 266 FOREIGN SYSTEMS OF OLD AGE PENSIONS AND INSURANCE Nearly every European country, in addition to Australia, New Zea- land and Canada has some form of state provision for old age. In the United States the only provision under government auspices is the Massachusetts Savings Bank Insurance, established in 1907 and the state insurance plan of Wisconsin, established in 191 1, both of which provide annuities to those voluntarily insuring. Annuity systems also prevail in England, Canada, France, Belgium, Italy and Spain. In England the plan dates back to 1864 when a postal insurance and annuity system was established. Canada adopted her system in 1908. In no instance are any considerable number of people insured under this plan. It is a form of voluntary thrift under state auspices. The prevailing European type is the compulsory old age insurance plan by which employed persons between certain ages are compelled to insure for the hazard of old age. The cost is divided between the state and the insured. In some countries the employers are also compelled to contribute. The following countries have systems : Germany, France, Sweden, Austria, Roumania, Luxemburg, and Russia and Italy for special groups. In all of these systems the state contributes a portion of the entire cost. The old age pension plan is the newer form of handling the problem and now prevails in Denmark (1891), Great Britain and Ireland (1908}, Australia (1908) and New Zealand (1898). Victoria, New South Wales and Queensland had previously established old age pension systems which were merged into the Australian Commonwealth system in 1908. In all of these systems the state pays the entire cost of pensioning' old people. The age limit for pensioning is 70 in England, 60 in Denmark, and in Australia and New Zealand 65 for males and 60 for females. Annuities Annuities are now sold by some insurance companies as a business proposition. In several European countries the government provides for the sale of annuities, and manages the business as a public function. Canada provides a department of annuities ; in Massachusetts the Savings Bank Insurance Act of 1907 provides for the sale of annuities in; small amounts to citizens of the state and in Wisconsin there is an annuity system. There are no other examples in this country of public annuity systems. Old Age Insurance The French' and German systems are perhaps the best examples of compulsory old age insurance on a large scale. The system was first adopted in Germany in 1889 and in France in 1910. In both countries the laws apply only to employed persons earning less than specified amounts. In France, payments are conditioned upon the payment of a67 premiums for 30 years, except that for men military service for two years reduces the period by* two years and for women the birth of each child reduces the period one year. In Germany, benefits to those 70 or more are conditioned upon 1200 weekly payments having been made, but pay- ments are not required during sickness. The French funds_ are derived from interest earnings, payments from employees, employers and the state. The German funds come from the employees, employer, the state and interest earnings. The French law grants a pension after 60 but any insured person may post- pone the liquidation of his pension until 65 or a smaller pension may be taken as early as 55 in case of disability. The pensionable age in Germany is 70, but an invalidity pension is granted to persons incapaci- tated from earning more than one-third of their usual income. The total number of persons insured in France in 191 3 was 7,854,- 132. The number receiving pensions in 1912 was 640,532. The number insured in Germany in 1914 was 11,788,922, and the total number receiv- ing old age pensions was 87,261, and those receiving invalidity pensions numbered 998,339. It will be seen that the age limit of 70 years in Ger- many greatly reduces the number of old age pensions and increases the number of invalidity pensions. Germany has recently reduced the pen- sionable age to 65. The amount expended in Germany in 1912 for benefits paid on account of old age was $3,349,539, and because of invalidity was $37,- 806,061. Old Age Pensions* The Australian and British systems are described as typical. Both systems were established in 1908 and in each case a straight pension is granted to aged persons who have an income of less than a specified amount. The pensionable age in Great Britain is 70, in Australia 65 for men and 60 for women. In Australia an invalidity pension is also paid by the state to persons over 16 who are permanently incapacitated. In Great Britain a person is disqualified from receiving a pension if he has an annual income of more than $153; if he has not worked according to his ability; if he has been imprisoned without the option of a fine within 10 years ; if he has been convicted of inebriety, or if he has secured poor relief after the pension has been granted. A pen- sioner must be a British subject and must have lived 12 of the last 20 years in the United Kingdom. The amount of the pension is small; before the war it was only about $63 annually, which is increased or decreased according to the other income of the pensioner." In Australia a person is disqualified unless he has been a resident 25 years (two years absence allowed) and unless he has led a sober and *For further details see Appendix E, "Old Age Pension Systems in the British Empire." 'Increased 50 per cent in 1918. 368 reputable life for at least one year and has not been imprisoned for four months within five years, or as much as five years in the last 25 years. Persons having property valued at more than $1500 are not allowed a pension. The maximum pension allowed before the war was $127,° and is reduced according to other income of the pensioner. The number of pensioners in the United Kingdom for the year end- ing March 31, 1917, was 947,780 or 62.2 per cent of the total number qualified by age for a pension (based on the census of 1911)- There were 91,783 pensioners in Australia June 30, 1916, or 34.5 per cent of those qualified by age to receive a pension, and in New Zealand -19,697 pensioners March 31, 1917, or 34.0 per cent of those qualified by age to receive pensions (based on census of 1911). Pensions for Public Employees. No special study of the public pension system for teachers, police- men and firemen and other public employees in Ohio, nor of the subject of a state retirement system for state employees has been made for the Commission. These subjects are closely related to the subjects covered by the Commission. They are attracting nation-wide attention and are recommended for special study in Ohio. The studies of pension funds in Illinois and the study of retirement pensions made in Massachusetts and New York and by the Congress of the United States point signifi- cantly to the need for the study of thesd problems in Ohio. RECOMMENDATIONS Assuming the need for a comprehensive system of care for the aged as proven, we are forced to choose one of threel methods. I. A voluntary annuity system. II. A compulsory contributory old age insurance system. III. A system of pen.sions payable to the aged out of the public treasury. The flrst of these methods as a means of meeting the old age problem comprehensively must be discarded. Experience everywhere proves that people do not voluntarily purchase insurance or annuities. After 40 years of experience in England only 150 persons annually purchase annuities under the post-office plan. In Massachusetts and Wisconsin, the number of persons who have taken advantage of the insurance pro- vided at cost under state auspices are insignificant when compared to the number requiring such provision. A plan for the purchase of an- nuities should, however, be formulated by the state or federal gov- ernment so that those who wish this method of voluntary provision for old age at cost may obtain it. This Commission has strongly recom- ' Increased September 31, 1916 up to a maximum of $158.14. 269 mended to the federal authorities that the purchasers of war savings stamps be allowed to convert them into annuities. The second plan, compulsory contributory old age insurance, has some fundamental difficulties which appear insurmountable. These difficulties are briefly summarized below. The present generation of aged people, because they have not paid oremiums throughout their working life, would not be benefitted, unless an exception were made and pensions were paid to them from the public treasury. Even those who are past middle life would be only partially benefitted and the returns from their insurance payments for a number of years would not be sufficient to meet their needs. A partial pension for them would be necessary, therefore. It would be fully 35 years before the system would be working satisfactorily as an insurance system without supplementing the insurance by a partial or full pension. It would be necessary to keep an account with all employed persons from the time they began work until death. The shifting of population from state to state, from place to place and from employer to employer makes the problem difficult, if not impossible of solution. The details of such a plan would be exceedingly complicated and the expense very great. The problem differs from that presented, by health insurance because old age insurance, like life insurance, is insurance for a hazard in the distant future, whereas health insurance covers primarily the haz- ards of the immediate present. Under the former the insured derives no immediate benefit from his accumulated payments; under health in- surance, with the ever present risk of sickness, the insured benefits from the "protection" even though he may not be ill and may not require the benefit. Partially on this account "surrender values," which the law compels life insurance companies to provide for those whose policies lapse after premiums have been paid for a number of years, have not developed- in health insurance. Instead, when a man ceases health insur- ance payments, his account is closed. As in Hfe insurance so in old age insurance, a man who fails to continue his policy should receive a sur- render value. In a state system of obligatory old age insurance this would mean that when a man insured against old age leaves the state or for other reasons ceases to be insurable, he is entitled to at least a portion of the accumulation from his own payments. The constant fluc- tuation of the transient population would involve a scheme of old age insurance in endless difficulties. The provision for a worker's life and dependents after they become aged is another problem which cannot be adequately solved imder old age insurance limited, as it is customarily, to wage-earners. A large part of the dependent aged are widows. They were never wage-earners and consequently would have no rights under an insurance plan requiring contributions from income. Theoretically the problem might be solved by increasing the rates to cover a man and his wife but actually the 270 burden would be, under present conditions, too heavy for the wage- earner to bear alone. A subsidy by the state or by the employers would make the scheme partially a pension system. The same problem arises in connection with the employer, the man of small business, the self- employer or the wives and dependents of such persons who may reach old age without a competence as a result of misfortune of one kind or another. The cost of administration would be high because of the extensive and detailed account keeping with large numbers of people. Moreover, it would raise the question whether the money thus spent could not be more effectively used if it were applied directly to the payment of pen- sions. In view of the diffictilties accompanying the introduction of a com- pulsory old age insurance plan and the certainty that a voluntary an- nuity system would not meet the needs, we are forced to consider the alternative of a pension payable out of the public treasury either from moneys collected by the regular system of taxation or by a special tax designed particularly for the purpose. The old age pension plan has the virtue of simplicity. It is com- paratively easy to administer, involving only the determination of the age of the applicant, and other easily determined facts such as the length of residence, citizenship and recent moral record. The State of Ohio already has had experience with similar problems and has solved them jy the pension system. Pensions for the blind have been paid for some years and mothers' pensions have been paid since 1913. Nearly $r,ooo,- 000 annualy is paid out for these pensions. Under the insurance plan the direct contribution made from wages has the advantage of making the insured person feel directly and per- sonally responsible for his old age. The same result could undoubtedly be reached by a special tax which would be equitable upon all, such as a graduated income and an inheritance tax, supplemented by a tax upon production or a tax possibly upon those industries which do not hire or retain the older men. However, the use of the regular machinery of taxation for the collection of an equitable tax for pensions to the aged certainly has advantages over a separate system of collection, organized upon an insurance system. There are safeguards which should be thrown around an old age pension system to prevent the danger of pauperization and of dependence upon the state. The pension should be low enough to prevent voluntary dependence upon it as the entire support for old age. A plan of volun- tary annuities for old age should be incorporated in the pension plan in order to encourage supplementing the pension. Provision for de- ferred pensions, under which the pensioner would receive a larger pension by deferring acceptance beyond the age at which he is legally eligible, would be advantageous in encouraging special thrift. 271 The pension plan approved by the majority of the Commission pro- vides for an old age pension of not over $5 a week beginning at age 65. No pension is to be paid to a person who has an annual income of $350 or more; and the amount of the pension to persons having an income less than $350 a year, is to be apportioned in such a way that the total annual income shall not exceed $350. Property possessed by a pensioner shall revert to the state upon the death of the pensioner to be used to reimburse the state for pensions paid. Any part left over will then be given to the lawful heirs, if any. The following persons are excluded : I. Aliens and persons who have been citizens for less than 15 years. II. Persons who have not been residents of the state for 15 years. III. Persons convicted of a penitentiary offense within 10 years. IV. Persons who have disposed of any property in order to qualify for a pension. V. Tramps and professional paupers. The whole system should be administered by the state through a state pension commission of four members. Local administration, it is urged, should be combined with other welfare work of the county under a board of county welfare. OLD AGE PENSIONS IN THE UNITED STATES. No system of old age pensions is in force in continental United States but the territory of Alaska has an optional system whereby an aged person may receive a monthly pension of $12.50 in lieu of going to the Pioneers' Home at Sitka. The recipient of a pension must be 65 years of age or over and a resident of Alaska for 10 years or since 1905. Arizona adopted an old age pension plan through an initiated act adopted November, 1914, but being crude and plainly unconstitutional in its form, it was promptly declared void by the Arizona supreme court. Several notable investigations of the subject have been made be- ginning in 1910 with a study by the special commission in Massachusetts. This commission, after sitting two years, reported adversely on the plan for that state. Both old age pensions and compulsory old age insurance were rejected and the statement was made that if any system were adopted it should be voluntary, although it was pointed out that "experience with vountary contributory schemes point to the inevitable conclusion that such a system never could become universal in its appli- cation." Four years later the Massachusetts Bureau of Statistics was author- ized to make a special census of the aged dependents. This census resulted in the accumulation of data, principally regarding the extent of puplic dependency of the aged. No recommendations were made. 272 The Boston Chamber of Commerce after a special inquiry in 1917 favored contributory old age insurance rather than pensions. The National Association of Manufacturers, through a special committee of which Mr. S. P. Bush of Columbus was chairman in 1918, issued a report which summarized the problem and advised as follows : We believe that evidence is lacking to prove a present necessity for the enactment of old age pension legislation for the civil population and we further believe that it is a moral responsibility of the private employer to encourage, assist and inspire his employees with the importance and necessity of ways and means for making provision for the contingencies of life, including old age. \ '^ Li *. Lli ■ Jl _: J^ ^.,i^' ■ : , I At the same time the sentiment for old age pensions has grown and resolutions endorsing old age pensions have been passed by many labor unions and other organizations. A minority of the Special Commission on Social Insurance in Mass- achusetts which reported in 1917 favored non-contributory old age pen- sions. This minority of the commission said in its statement:^ After studying the problem of "protecting wage-earners from the burdens of old age," we have concluded that it is a very different pi'oblem from other social welfare measures, in that there can be no recapitalization of energy and strength in the aged citizen. When old age comes to those without sufficient means, prospects of employment and health and other opportunities are passed, or quickly passing, all lessening the possibility of their providing for themselves, and we have them to treat humanely, with love and respect, or to throw de- liberately on the scrap-heap, like human junk, to be neglected till death brings them peace. Therefore we are convinced that the Commonwealth, should establish at once a system of non-contributory old age pensions to protect our deserving aged citizens, both men and women, who are without sufficient means and unable properly to provide for themselves. We have reached this conclusion from the evidence given at our hearings and from the knowledge of the continuously in- creasing and intense demand for such pensions prolonged over a period of years in Massachusetts. We hold that the so-called non-contributory system of pensions is the most humane and equitable ; that such protection is an inalienable right of good citizen- ship; and that a Christian state or nation, dedicated to the welfare of its people, cannot) with honor continue to degrade its worthy aged people through pauperism after they have given of their strength and vigor to create its wealth, its great- ness and its glory. Subscribing to the principle of non-contributory old age pensions they quote Hon. Lloyd George with approval:^ The fir,st general criticism is that this is a non-contributory scheme . . . I ' demur altogether to the division of the scheme into contributory and non-con- tributory. So long as you have taxes imposed upon commodities which are con- sumed practically by -every family in the country, there is no such thing as a naij-contributory sclieme. You taX tea and coffee, sugar, beer and tobacco, and ' Massachusetts, Report of the Special Commission on Social Insurance, 1917, p. S3. " Massachusetts, Report of the Special Commission on Social Insurance, 1917, p. 54. 273 you get a conltribution from practically every family in the land one way or an- other. So, therefore, when a scheme is financed out of public funds, it is as much a contributory scheme as a scheme which is financed directly by means of contributions arranged on the German or any other basis. A workman who has contributed health and strength, vigor and skill, to the creation of the wealth by which taxation is borne, has made his contribution already to the fund which is to give him a pension when he is no longer fit to create that wealth. There- fore I object altogether to the general division of these schemes into contributory and non-contributory schemes. There is, however, a class of scheme which is known as the contribiitory. There is the German scheme, in which the workmen pay into a fund. It is rather a remarkable fact that most social reformers who have taken up this ques- tion have at first favored contributory schemes, but a closer examination has almost invariably led them to abandon them on the ground that they are unequal in the treatment of the working class, cumbersome and very expensive, and in a country like ours hopelessly impracticable . . . Let me give you now two or three considerations why, in my judgment, a contributory scheme is impossible in this country. In the first place, it would practically exclude women from its benefits . . . Another consideration is that the majority of the workingmen are unable to deflect from their weekly earnings a sufficient sum of money to make adequate provisions for old age, in addition to that which they are now making, for sickness, infirmity and unemployment.' The report further quotes the former premier, Mr. Asquith, A. Bonar Law, Arthur Henderson, Phillip Snowden, John Redmond, F. Herbert Stead and Sidney Webb, in hearty commendation of the old age pension system in England. The statement by Sidney Webb is sig- nificant :° The old age pensions act has by universal testimony been an unqualified success, a pure gain with almost no drawbacks. Fraud has been very small (and then only venial) . . . The experience of New Zealand and Australia has been the same, and the number of paupers over 70' years has been enormously reduced; there are now hardly any outdoor paupers over 70, whilst of the indoor paupers there remain only the chronically sick or feeble-minded or incapable, to whom the workhouse is a home of rest. No political party would dare to suggest repealing the act; in fact, no one has ever done so. Another minority of the 1917 Massachusetts commission held that "the time is not ripe for the adoption of any system of old age pensions in Massachusetts," because "there does not appear to us to exist any wide spread need." They stated that "the present system of institu- tional care or outdoor relief is admittedly adequate to meet the sufifering so far as it is a physical problem," and they suggested that it would be simpler to provide that aged recipients of relief should not be deemed paupers. The minority specially urged the necessity for a living wage sufficient to provide for present necessities and also for the contingencies of life including old age.^° "Massachusetts, Report of the Special Commission on Social Insurance, 1917, p. 83. "Ibid., p. 97. 18 CHAPTER XXI THE COST OF OLD AGE PENSIONS The first matters to be considered in discussing the cost of old age pensions are the extent of old age and the number of persons who would probably be eligible for a pension. The number of persons 65 and over in 1910 in Ohio was 261,810 of whom 129,598 were males and 132,212 were females. The estimated number of people 65 and over in 1918 is 304,137. It is estimated that the number will be 314,718 in 1920 and 341,173 in 1925. At present, therefore, we know with fair degree of exactness the number of persons who would be qualified by age to receive a pension if an old age pension system were adopted. When we come to the question of determining the number of persons who would be entitled to a pension^ upon the conditions laid down in another place we find many difficulties. There are no census figures available. There are, however, some very excellent guides for the esti- mation of the approximate number who would be entitled to a pension. Assuming that a person would not be entitled to a pension if he had an income of $350.00 a year from other sources and that if he possessed property, it would be held by the state for reimbursement, we can apply to the solution of the problem some of the statistics from the census relating to property ownership. In 1910, 51.2 per cent of all homes were owned in Ohio and 71.8 per cent of all farm homes were owned. In 1910 farmers were classified by age and it was found that 32,007 were 65 years of age and over and that 28,266 of these owned their own farms and 24,406 owned their farms clear. It is unlikely that many persons who own their farms free from encumbrance at 65 will ever come upon the pension roll and if, for lack of income, they should, they would have property at death with which to reimburse the state for such payments. The statistics of home ownership in Ohio among persons 65 and over in 1900 show that 39,414^ such persons other than farmers owned their own homes free, making in all a total of about 77,321 persons 65 and over who owned their own homes free while 13,487 owned encumbered homes. The number of wives or husbands of owners who are 65 and over is unknown. There were in 1917 on the federal pension rolls 63,703 people from Ohio, practically all of whom were over 65. Many of these, of course, *In 1910 there were 30,585 farm homes in Ohio owned free by persons 65 and over. (274) 275 are home owners and a deduction of not more than half would be justified. A number of people 65 and over are not home owners but are possessed of other property which is probably sufficient for their needs, and a small deduction from those otherwise pensionable should be made on account of these. There were 113,856 foreign-born persons over 21 in Ohio in 1910 who were not naturalized. The number 65 and over is unknown but may be estimated at a minimum of 10,000. A small number of people would lack the residence requirement of 20 years fixed by the Commission. Exclusions because of pauperism, imprisonment, drunkenness, etc., would exceed 10,000. Approximately 11,000 aged persons are cared for in infirmaries and old folks' homes, half of whom would not be eligible for a pension. The aged persons 65 and over in insane hospitals and other benevolent institutions would of course be cared for as at present and pensions would not be paid to them. From' 6,000 to 8,000 would thus be deducted. The estimate from all of these overlapping figures must be some- what arbitrary and yet we believe it would not be far from the exact number to say that not over 80,000 would be entitled to a pension under the conditions laid down. As collateral proof of this estimate, we may draw from the experi- ence of Australia where in 1916 the persons receiving pensions consti- tuted 34.5 per cent of all persons eligible by age, and from that of New Zealand where in 191 7, 34.0 per cent of those eligible by age were allowed a pension. Accepting 35 per cent of the total qualified by age as a liberal estimate we find that on this basis 106,447 would be eligible under the proposed plan. For a number of years to come, however, we must arbitrarily reduce this number by at least 30,000 to 35,000 federal pensioners who already draw from their pensions an income greater than the minimum fixed by the proposals of this Commission. An estimate on the basis of the experience of Australia would, therefore, give be- tween 72,000 and 77,000 as the number eligible for a pension. We believe that 75,000 to 80,000 is a reasonably conservative estimate in the light of all the information we possess. A pension of $3.00 per week would, therefore, entail a charge of $225,000 to $240,000 weekly or $11,700,000 to $12,480,000 annually in addition to the cost of administration. This according to the experience of Australia and New Zealand, would be about $1,000,000 annually. It is not unreasonable to expect, however, that the experience of the Industrial Commission of Ohio may be duplicated and the entire system be admin- istered at 3 per cent to 4 per cent of the gross amount or at an expense well under $500,000 The annual expediture would be, therefore, as a maximum not more than $12,200,000 to $12,980,000. At the maximum of $5 per week the total annual cost would be $20,000,000 to $21,300,000. 276 The experience of New Zealand is that 75 per cent to 87 per cent of the pensions are full pensions. This factor would materially reduce the total required expenditure. Accompanying the plan to pay a pension directly out of the public treasury to all persons' 65 and over who quahfy, there should be estab- lished a voluntary system of annuities whereby a person by his own con- tributions may accumulate an old age annuity to increase the pension granted by the state. The Commission recommends the following two voluntary plans for adoption. The first is a plan whereby any person may by periodic payments or by lump sum payment purchase an annuity not exceeding $6 a week. A voluntary old age annuity plan supplementing the pension system would be simple in its operation. The state would manage the plan on strict actuarial lines and be obligated for nothing except honest manage- ment and the care of the funds. Some illustrative examples will more clearly set forth the scope of the annuity system, (a) If the sum of $25 is placed to the credit of a child at ten years of age in an annuity fund, it will purchase for that child a guaranteed payment of $54.59 annually, so long as he lives after 65 years of age. (b) If a man pays 50 cents a month into an annuity fund during his working days, from 16 to 65, he will receive $186.91 annually thereafter for as many years as he may live, (c) If a person at 40 places $500 in an annuity fund, he will be entitled to receive $261.38 a year for every year he lives after 65. (d) If a person at 65 has $1,000, he can purchase with it an annuity payment of $120.42 to continue as long as he lives. The plan would furnish a means of promoting thrift and unless a system of annuities were established by the federal government would afford the only means by which old age insurance could be purchased at a reasonable cost. The second is a plan whereby a person who is qualified for a pen- sion at 65 may defer taking his pension and may thereby increase the pension which he receives when he goes upon the pension rolls. The amount which he is entitled to receive from the date when he becomes eligible to the date when he finally claims his pension would be calculated on an annuity basis and added to the pension to which the law would entitle him. The plan to encourage pensioners at 65 to keep off the pension roll so long as possible and be rewarded by increased amounts is a means of encouraging thrift. The plan is simple and an example clearly explains it. For example, a man at 65 would be entitled to claim and to receive a pension of $3.00 a week. He may, however, still be able to work and to maintain himself or he may have friends or relatives who would help him if an incentive to special thrift were given. That incentive is offered in increased weekly payments equal to the amount which his deferred payments would purchase as an annuity. If he remained off the pension 377 list for five years the pension at age 70 would amount to $5.59 a week so long as he lived. Modifications of the same plan might be offered so that the pen- sioner could have part of his pension accumulate for an increased an- nuity. This plan here outlined is not in operation in any of the countries which have a pension system similar to the one proposed. It has the elements of constructive thrift and should appeal to thosi; who argue that a non-contributory pension breaks down the self-reliance and thrift of the individual. It would also be a safeguard against the insistence which might arise for the enlargement of the pension and the lowering of the pensionable age. CHAPTER XXII MINORITY REPORT ON OLD AGE PENSIONS M. B. Hammond I do not wish to have my report regarded as one which dissents from the conclusions of the majority of the Commission on this subject, but rather as the report of one who does not find in the evidence which had been presented to the Commission at the time we were compelled to formulate our recommendations sufficient information to enable him to accede to these recommendations. Further information and discussion might lead me to agree with the recommendations of the majority. Any-one who has gone carefully through the pages of this report cannot but be struck with the fact that the information on the subject of old age pensions or old age insurance or any other method of meet- ing the old age problem is much less abundant and conclusive than is the information on the subjects of sickness prevention and health in- surance. The careful investigation of the conditions affecting the life of the aged poor in the county infirmaries and private homes, as well as in certain communities of the state which has been made for the Com- mission by Father O'Grady, of our staff of investigators, points clearly to the need of some intelligent method of affording relief to the aged, respectable poor who rightly wish to avoid the stigma and associations of pauperism. These investigations do not, however, indicate the nature of the solution of the problem, and the author does not make any such claim for them. No investigation was made by any of the Commissioners nor by any one of the investigators of the actual workings of the systems of old age pensions in those countries which have adopted such a system of caring for their aged poor. The funds appropriated by the Legis- lature could not be spent for the purpose of making such an investiga- tion and it probably is not necessary that such a first-hand investigation should be made by an Ohio Commission. There are available, however, certain Parliamentary reports of investigations made into the workings of the system of old age pensions in Denmark, Australia and New Zea- land and into the results of the old age pensions allowed to civil servants in Great Britain, but the results of these official inquiries had not been presented to this Commission, nor were the conclusions of even secondary authorities digested and presented to the Commission in time for their consideration prior to the time when they were asked to make recom- mendation on the subject. I have made some study of the material here (278) 279 referred to but it has not been sufficient for me to reach a definite'con- clusion in regard to the desirability of old age pensions. It has been sufficient, however, to raise certain questions in my mind which I have presented in the summary of my minority report given in the first chapter of this report. Until I have had a satisfactory answer to these questions and an opportunity further to study the evidence relating to old age pen- sions or old age insurance, I do not feel that I can join in any recom- mendations to the Legislature for or against either old age pensions or old age insurance. Since I have raised these questions in the Summary, it is perhaps my duty to discuss these matters further and to give more fully the reasons why I am not sure that old age pensions — to which the pensioned persons have made no direct financial contributions — offer the relief from the burden of old age which is sought by those who favor such pensions. I. This country has had no experience with a system of old age pensions but it has had considerable experience in the way of pensioning men who have been in the military or naval service of the country during a time of war. The results, I believe, are not usually considered fortunate ones. The experience has been especially unfortunate in the field of service pensions. Until the year 1890, pensions had been paid in the United States O'nly to men who had sufifered some disabiHty in the military or naval service of their country, or to the dependents of men killed or disabled in such service. Although the attitude toward such disabled soldiers and sailors has been one of increasing liberality, this generosity can easily be defended on the ground that a man who had been killed or disabled in the service of his country had a special claim that neither he nor those de- pendent on him should suffer financial dependency or pauperism as a re- sult of his death or disability. The service pensions, however, have had no such solid grounds on which to stand. They are offered to all men who have served in specified wars for specified periods of time and to the widows and orphans of such men, without reference to any disabilities incurred in the service or to the cause of their death. It would be too much to say that the members of Congress who have voted these service pensions have been actuated solely by a political motive — the desire to build up a constituency favorable to themselves. But certainly the influence of a compact group of people, the pensioners and their friends, has not been the least of the influences which have made for the establishment and continuance of the service pensions. The most of these pensions have been alloted to survivors of the Civil War and their dependents. As year by year the Civil War receded into the past, it was natural to suppose that the number of pensioners would grow less and the amount of money appropriated for the payment of such pensions would diminish. This has been true of the disability 28o pensions and pensioners, but 50 years after that war was over we had witnessed hardly any diminution in the appropriations for service pen- sions. The service pensions were begun in 1890. In 1893 the total amount paid amounted to slightly more than $56,000,000. By 1914 the amount had grown to $94,500,000. There have been several reasons for this growth. A recent official report gives these reasons as follows : Since 1890 the monthly rates for service pensions have been repeatedly raised. . . . Not only have the rates of the Civil War service pensions been raised since 1890 but the limitations concerning disability or dependency have been relaxed. At first a man was eligible to a pension only if he were in- capacitated for manual labor although his disability need bear no relation what- ever to his Civil War service, and a widow must have been without means of support other than her own daily labor. Now, however, age without disability entitles a man to a Civil War service pension, and any widow who was married before June 27, 1905, to a man who had served 90 days in the Civil War is entitled to a pension without regard to dependency.' Is it any wonder that, under these circumstances Congress decided at the time this country entered the great European War, that a better mode of furnishing relief to soldiers and their dependents, and of affording protection to Congress itself, was to be found in the establishment of a system of war risk insurance? That a system of non-contributory old age pensions would subject our legislatures to the same political pressure constantly to increase the amount of the pension allowed and to enlarge the list of those entitled to a pension as has been applied to Congress in the case of the Civil War pensions is hardly to be doubted. Indeed, such has been the case in other English speaking countries. New Zealand, which has had the system in operation longer than has the motherland, or any other of the colonies, offers the best example of this pressure. The system was adopted in that country in 1898 when the amount of the annual pension was fixed at f 18 ($87.58) for persons 65 years of age and over who did not receive an income of £52 ($253.03) or more per year. The act received important amendments in 1900, 1902, 1905, 1908, 191 1 and 1914, always in the direction of making the pension allowance greater or the number of persons eligible to a pension larger. The amount of the pension has been raised to £26 ($126.51), and the age at which it may be granted has been reduced to 60 years in the case of men and 55 in the case of women. The amount of independent income which may be re- ceived by pensioners without sacrificing the right to a pension has been raised to £60. The provisions regarding the holding of property, the length of absence from the Dominion, moral qualifications, etc., have been "liberalized"' in such a way as to enlarge the pension list. 'Capt. S. Herbert Wolfe, "Governmental Provisions in the United States and Foreign Countries for Members of the Military Forces and Their Dependents," United States Department of Labor, Children's Bureau, Miscellaneous Series No II, 1917, pp. 20, 21. 28l In 191 1 when the amendment to the old age pension act had been passed, the Evening Post of Wellington, which has always favored the progressive social legislation of the Dominion, gave the following edi- torial expression to this tendency to amend the old age pension act: "Whatever other business has to be neglected, Parliament is never too busy to amend the Old Age Pensions Act. It is a measure which makes a strong appeal both to the sentimentalist and to the politician, and unfortunately the combination has constantly proved strong enough to overpower the voice of prudent statesmanship. . Theoretically, the self-interest of the citizen im- poses a stronger check upon extravagance in a democracy than under any other form of government, yet in practice we unfortunately see that the general interest of the taxpayer in the maintenance of economy is often so diffused, languid and feeble a force that the politician who is accustomed to take the line of least resistance finds it a much simpler and safer matter to yield to the pressure of a small but insistent section. (Oct. 18, 1911.) This one-sided pressure would not be present in the case of old age insurance to which those who were ultimately to be eligible to an annuity were compelled to. contribute a part of the funds during their working years. Demands for an increase in the amount of the annuities and for enlarging the eligible list would still be made, but they, would meet the resistance of those who did not desire to increase their contri- butions to the fund. The result would be that the legislature would have an opportunity to weigh the arguments for and against the policy of extension. Whatever amendments were made would follow the dictates of reason rather than those of sentiment and political fear. II. The recent agitation for old age pensions in this country has come largely from organized labor and undoubtedly the wishes of our laboring classes should have much to do with the formulation of a policy for caring for the aged poor as well as for carrying out any plan of social reform. If I felt that the leaders of organized labor had decided on a policy of old age pensions after carefully considering the reasons which lead to the adoption of the system in other lands and after ac- quainting themselves with the attitude of the people of those countries in regard to the old age pensioner, I should feel much less hesitation in supporting such a scheme. I do not find, however, in the writings of those who favor the plan that much consideration has been given to this phase of the subject. It is usually said that the pension scheme is popu- lar with the pensioners and their friends and that no legislature would think of repealing the act, but little is said as to the way in which the pensioner is regarded by the rest of the community. Is he thought of as a recipient of poor relief, or as an old man, freed from the necessity of toil, who is now enjoying the fruits of the labor of his earlier years? I confess that from what I was able to gather from chance remarks, un- consciously made, by persons whom I met in Australia and New Zealand, the pension is more often thought of as a method of poor relief than 282 otherwise. In both those countries old age pensions were adopted in the absence of any other systems of caring for the aged but dependent poor. In Denmark the pensions are administered as a part of the poor law sys- tem, but an effort is made to distinguish between the old aged pensioners and the recipients of other forms of poor relief. In Great Britain the adoption of the system came at the end of a movement extending over some years for a reform of the poor law system. Now, if there is any one thing more than others which one who has had occasion to meet frequently with representatives of organized labor in this country carries away from such meetings, it is that the independent working-man in this country resents any form of govern- mental assistance which smacks in the least of charity. Would such a man favor old age pensions if he knew that by other members of the com- munity they would come to be regarded as a form of charitable relief? Yet, one who wishes to face the situation frankly is obliged to ask, what is an old age pension, if it is not charity? Is it not of the very essence of charity that it is something given to the recipient without any return on his part? And since it is not made a condition to the grant of an old age pension that the pensioner be required to contribute to the funds from which the pension is drawn, just how is this form of assistance to be distinguished from any form of public charity? Dr. Samuel John- son many years ago defined a pension as "an allowance made to any- one without equivalent." This, however, brings us to the third point. III. The only alternative to regarding the old age pension as a form of poor relief is to consider it as something to which the recipient is entitled as a matter of right — something which he has earned previously but is only now receiving. This argument is frequently made in support of our Civil War service pensions. They are said to be merely a form of "back pay." But if old age pensions are to be considered as a form of deferred pay, why is the payment deferred? Do the wage-earners desire to receive their wages in the form of partial payments at the time the labor is performed and the balance when they reach old age, if ever they do reach it? Most wage-earners, I dare say, will prefer to have their wages when they earn them. Whether old age pensions are, as a matter of fact, merely deferred wages is something concerning which we have no adequate information. President Pritchett, of the Carnegie Foundation for the Advancement of Teaching, says in an article in the Atlantic Monthly for December, 1918, that the results of the operation of the old age pension plan of the British civil service which has been in operation since 1857 have clearly shown that pensions paid under that plan were really deducted from the wages. In this case it must be remembered that the pensions were paid by the same employer who paid the wages. I have made some examination of the Parliamentary reports which doubtless furnished the evidence on which President Pritchett relied in support of his state- 283 • ment, and I do not find the evidence so conclusive as he seems to find it. But, even if this were the effect of a pension scheme maintained by a government for its own employees, different results might follow from a scheme where the wages were paid by a private employer and the pen- sions were paid by the government. We would have to know how far the prospect of a pension tended to weaken the employee's bargaining power, and how far the additional taxes which the employer had to pay as a result of the pension plan affected his ability to pay the wages current in other states. These problems cannot be solved on the basis of information now at hand. We need further study of the subject. IV. Closely related to the subject of wages is the problem of the mobility of labor. What- effect would a system of old age pensions in this state have in causing an influx of laborers into this state and in preventing the normal outflow of men from the state when higher wages were offered elsewhere? The plan recommended in the report of the majority of the Commission seeks to prevent men being attracted into the state by the prospect of a pension by requiring a residence of 15 years in the state before the claimant is eligible for the pension. This might check the movement into the state but what about the move- ment out of the state? Would a man in need of employment and who would otherwise leave the state to accept work offered elsewhere, do so if he thereby lost his right to claim an old age pension in Ohio? If he did not and if this were the result Of the system in many cases, it would follow that the state would soon have more than its fair propor- tion of men above 45 or 50 years of age, who experience shows, are the hardest to place in regular employment. V. The argument that old age pensions would discourage thrift is often made and as often answered. Undoubtedly, there is much to be said on both sides. Without pushing this point to extremes, how- ever, one may well question the wisdom of a system which entirely re- lieves a man from the obligation to assist in providing for his old age. A plan of old age insurance, which encourages the worker to save a part of the sum necessary to provide for his declining years by offering to supplement such savings by contributions made by the state, and perhaps by others made by employers, would seem to be more in ac- cord with the generally accepted doctrine of self-help. VI. The estimates of our investigators fix the probable cost of a system of old age pensions at something more than $12,000,000 annually when once the plan is in full operation. This estimate is based on the supposition that a pension of $3 a week might be allowed to those eligi- ble. The recommendations of the majority of the Commission, if adopted, would, however, call for a sum somewhat larger than this, as the maximum allowance to any man might be as high as $5 a week. It is not easy to calculate the probable costs on the basis of these recom- mendations, since under this plan the amount of the pension would 284 vary with the income of the pensioner. How to secure the revenues which would make such a system of old age pensions possible is a ques- tion which the Legislature would find some difficulty in answering. The financial difficulties should not prevent the adoption of the plan, if it is otherwise found' desirable. The burden of old age has to be borne in any case and the only question is: on whose shoulders shall the burden fall? As it is at present the burden rests on the aged people themselves and on their relatives. Under a system of old age pensions it would rest upon the taxpayers. Under a system of old age insurance the financial burden would be distributed among the wage-earners prior to their reaching the pensionable age, the taxpayers and possibly the employers. Whether the system ultimately adopted be that of old age pensions or old age insurance, the state will have to provide additional revenues to meet the increased expenditures made necessary by the new method of caring for the aged poor. There is no doubt that the State of Ohio can carry this load as well as do most of the countries which have adopted either of these methods of solving the old age problem. Before either plan is adopted, however, the General Assembly should carefully consider the financial problems involved and revise the revenue system of the state in such a way as to assume its share of the financial obliga- tions involved. To repeat what I said at the outset, I cannot recommend to the Legislators of this state the adoption of any system of old age pensions or old age insurance or any other comprehensive plan of caring for the aged poor of the state which calls for the appropriation of immense sums from the public treasury until further study of the subject has pointed to at least a partial solution of the problems raised in the foregoing dis- cussion. APPENDICES (285) (: (: APPENDIX A THE HEALTH INSURANCE MOVEMENT IN THE UNITED STATES John R. Commons A. J. Altmeyer The term "social insurance" in its widest sense includes all in- surance, since insurance is but the social distribution of individual loss. But the term as here used applies to those forms of insurance, made more or less universal by governmental compulsion or subsidy which protect the wage-earning class against personal hazards. Social insur- ance is universal compulsory insurance of workers' welfare. In Ger- many, the term first used was Arheiterversicherung rather than Sosiale Versicherung. In this country the first men to write comprehensive treatises on the subject used the term "workingmen's insurance." Social insurance at present covers unemployment, accident, sick- ness, invalidity, old age and death, or rather survivors' insurance. These diiiferent forms shade one into another somewhat. Old age may be considered a form of invalidity and, in fact, is included in Germany with invalidity. Invalidity may be considered extended sickness and, accordingly, in England, is included with sickness. EARLY WRITINGS ON SOCIAL INSURANCE IN THE UNITED STATES The first writer in this country who made a comprehensive study of social insurance was John Graham Brooks. His book was published in 1893 as the Fourth Special Report of the Commissioner of Labor.^ It was the result of three years' study of social insurance in Germany, made at the request of Carroll D. Wright, then Commissioner of Labor. Dr. brooks was very favorably impressed with the working of the Ger- man system. His conclusions were: The three branches of the German national workmen's insurance — the sick- ness, accident, invalidity and old age insurance — supplementing each other mntnally, form a complete organization and have resulted in the formation of a new working-men's code, which in thei inevitable fluctuations of modern industrial life, will afford to all those in need of assistance a welcome aid, and in its further development cannot fail to exercise a great and salutary influence in the economical and social conditions of the working people ; indeed, on the whole nation. 'John Graham Brooks, "Compulsory Insurance in Germany," Fourth Special fieport of the Commissioner of Labor, Washington, 1893, (287) 288 The report by Brooks does not seem to have aroused much in- terest. The next book on the subject was that of Dr. W. F. Willoughby, pubHshed in 1898.^ This work covered the entire social insurance movement in Europe. The author did not unquahfiedly recommend the adoption of the entire program of social insurance for this country. He states*: As regards insurance against sickness, nothing short of absolute necessity would seem to warrant the intervention of the state. The arguments in favor of compulsion are much stronger in the case of insurance against accidents. ACCIDENT COMPENSATION The first form of social insurance to come into prominence in this country was accident compensation, generally termed workmen's com- pensation. Willoughby had suggested that this might be made com- pulsory, but Dr. Adna F. Weber of the New York Bureau of Labor was the first to present a detailed study. His report was published in 1899 and seems to have been the first contribution that definitely sep- arated out workmen's accident compensation from other forms of social insurance.* Prior to that time agitation had been confined entirely to measures designed to broaden the employers' liability laws. As Willoughby remarked in 1898: The most depressing feature of the situation lies in the fact that the very principles involved in this gradual evolution from the limited liability of employers to that of the compulsory indemnification by them of practically all injured em- ployees, are as yet not even comprehended in the United States." It was not yet clearly perceived that extension of the law of neg- ligence would not avail. No analysis of accident statistics had been made in this country to show the large proportion of accidents not due to any one's negligence, either that of the employer, the employee or a fellow servant. Even had this been realized, public opinion was not yet ready to admit that industry, as represented by the employer, must pay, regardless of negligence. In 1899 an effort was made in New York to pass a bill based on the principle of absolute liability and compensation, but it failed on account of the contemporaneous demand for a more stringent liability law.' ' ; : n ^W. F. Willoughby, Workingmen's Insurance, 1898. = Ibid., p. 344. 'Seventeenth Annual Report of Bureau of Labor Statistics of New York, 1899, pp. 567-1162. "W. F. Willoughby, Workingmen's Insurance, 1898, p. 329. ' Charles R. Henderson, Industrial Insurance in the United States, 1909, p. 144. 289 It Js significant that the agitation for workmen's compensation in this country took definite shape immediately after the passage of the British workmen's compensation act of 1897. Undoubtedly, the move- ment here was stimulated by the passage of that act and subsequent amendatory acts, including the workmen's compensation act of 1906. All of the British acts provided for compensation to be paid largely without regard to individual responsibility. The crude, inadequate and unworkable law of Maryland in 1902 marks the beginning of workmen's compensation legislation in this coun- tr)r.' The federal workmen's compensation act of 1908 was the first workable compensation act, inadequate though it was. In 1909 the states began to appoint special legislative commissions to study the problem. The reports of these commissions, together with the report of the United States Bureau of Labor in 1909, furnished an abundance of information.* In 1910 both Montana and New York passed acts which were later declared unconstitutional. The year 191 1 marks the date of the first permanent state laws. In this year the following ten states in the order named passed compensation laws : Washington, Kansas, Nevada, New Jersey, California, New Hampshire, Wisconsin, Illinois, Ohio and Mas- sachusetts. Today there are thirty-eigh-t states and three territories with such laws.' Dr. Weber in 1902^° and Professor Seager in 1910^^ both ventured the opinion that the English system of workmen's compensation, wherein the employer is permitted to select his insurance carrier, rather than the German system of compulsory insurance in mutual societies, was best suited to conditions in this country. Their opinions seem to have gauged the American attitude correctly, since in thirty of the states the employer is given an option as to the method of insuring his risk^^ and in twenty-eight states self-insurance is permitted.'^'. OCCUPATIONAL DISEASES While the states were still in the process of passing compensation acts covering accidents, agitation was begun to include occupational diseases. Possibly the fact that certain occupational diseases were cov- ered in the British compensation act of 1906 may have had some in- ' United States Bureau of Labor Statistics, Bulletin No. 240, "Comparison of Workmen's Compensation Laws of the United States," 1918, p. 10. 'Twenty-fourth Annual Report, U. S. Commissioner of Labor, 1919, 2 Vol. 'United States Bureau of Labor Statistics, Bulletin No. 240, 1918, p. 9. "Adna F. Weber, "Employers' Liability and Accident Insurance," Political Science Quarterly, Vol. XVII, 1902, p. 282. " Henry. R. Seager, Social Insurance, 1910, pp. 74-75. "United States Bureau of La;bor Statistics, Bulletin No. 240, 1918, p. 15. "Ibid., p. 40. 19 290 flueiice in this discussion. In 1910, Dr. John B. Andrews, secretary of the American Association for Labor Legislation, said:^* No intelligent person can go far in the study of compensation for industrial -accidents without realizing that a logical consideration of the facts must lead to compensation for industrial diseases. The logic of providing compensation for occupational diseases is apparent from the definition : "Occupational diseases are morbid results of occupational activity traceable to specific causes or labor con- ditions, and followed by more or less extended incapacity for work."^° The great obstacle to legislation along this line is the difficulty of ad- ministration. In some states the word "injury" in workmen's compensation acts has been construed by the commissions and courts to include diseases. This is so in the case of Massachusetts and the federal government. In GaHfornia and Hawaii the inclusion of occupational, diseases has been brought about by statutory enactments.^* No state has followed the British plan of providing a definite schedule of compensatable occupa- tional diseases. This method is considered by the Committee on Occu- pational Diseases of the National Conference of Commissions on uni- form State Laws as "the only practicable way of dealing with the matter."" The British act of 1906 covered six occupational diseases, which number has since been increased to twenty-eight. Only the most appar- ent occupational diseases can be included (such as anthrax, lead poison- ing, glass blower's cataract) and even then the responsibility is often hard to fix. When the onset of the disease is gradual, as in the case of lead poisoning, it is hard to determine which employer is responsible, if the workman has been employed by more than one. If it is difficult to fix the responsibility in the case of those diseases to which the public at large is not subject, it is practically impossible to do so in the case of "diseases to which the public is subject, but which may be caused or aggravated or accelerated by specific conditions of Iabor."i« Undoubtedly, workers in the so-called "dusty trades" have an ex- cessively high death rate from tuberculosis, but it is impossible to establish the causal connection in individual cases. It is also true that monotony of work, speeding-up, a long work day and inadequate "Bulletin on Industrial Diseases and Occupational Standards, May 1910. ^^ American Labor Legislation Review, Vol. I, No. 1, Jan., 1911, pp. 125-143, "Memorial on Occupational Diseases." " U. S. Bureau of Labor, Bulletin No. 240, 1918, p. 45. '"Proceedings of the zjth Annual Meeting of the National Conference of Commissioners on Uniform State Laws, Saratoga, N. Y., 1917, p. 305. " See classification of the Committee on Occupational Diseases, whpse report has been referred to above. 291 wages undermine one's health and resisting power,^ but these facts could hardly be made the basis for legal action. A way out of the difficulty, which has been proposed, is to make industry responsible for all occupational diseases, the causes of which can be definitely allocated, and to provide compulsory contributory health insurance for all employees. Health insurance would then take care of occupational diseases not compensated. Advocates of compulsory health insurance point out that in the two states where occupational diseases are covered by the workmen's com- pensation law, the number of cases for which compensation is allowed is negligible.'-' While compulsory health insurance may be regarded as a logical development of accident compensation, it is more than an extension. Underlying both accident compensation and compulsory health insurance is the theory of social solidarity- In accident compensation the pur- pose was to make industry bear the cost of the damage and destruction of the human factor as it already did for machinery. Sickness, how- ever, may exist entirely apart from industry. THE AMERICAN ASSOCIATION FOR LABOR LEGISLATION It is interesting , to observe that agitation for health insurance began in this country in 1912, soon after the passage of the British national insurance act of 191 1, just as agitation for accident compensa- tion began soon after the passage of the British workmen's compen- sation act of 1897. The first attempt to formulate a plan of compulsory health insurance adaptable to conditions in the United States was that of the American Association for Labor Legislation in 1912. This association is a branch of the International Association for Labor Legislation, whose head- quarters are at Basle, Switzerland. The international association, which is a federation of associations in fifteen different countries, was founded at Paris in 1900 to promote progressive industrial legislation in all nations and an international knowledge of labor laws. Prior to the world war the international association received subventions from twenty-two national governments, including a contribution on account "For example, in Massachusetts, of 136,257 personal injuries reported to the Industrial Accident Board in the year 1915-^16, only 2,029, or 1.5 per cent., were cases of occupational disease. {Annual Report of the Massachusetts Industrial Accident Board, July, 1, 1915, to June 30, 1916, p. 70.) In California, in 1915, 67,538 injuries were reported to the Industrial Accident Commission, but from the time the law requiring the reporting of occupational diseases went into effect, August 8, 1915, to June 30, 1916, only 454 diseases were reported. It was thought tha:t these might be classed as occupational diseases, althoug'h at the time of. the report the commission had not definitely decided. {Report of the Industrial Acci- dent Commission of the State of Calif omia from July i, 1915 to June 30, 1916. pp. 42, 43.) 292 of services from the United States Department of Labor. Its publica- tions are issued in the three languages, English, French and German. The American association was founded in 1906 and affiliated with the international association. Its objects were to serve as a branch of the latter, to promote uniformity in labor legislation among the several states, and to encourage the study of labor legislation.^" Health insur- ance is but one of the several activities of this association, other activities being legislation for protection against accidents and disease, the taxation of poisonous phosphorus matches out of existence, the promotion of the federal compensation law, as well as workmen's compensation laws in various states, accident reporting and legislation to secure better adminis- tration of labor laws. In December, 1912, the association created its first national com- mittee on social insurance which organized the First National Con- ference on Social Insurance, held in Chicago in June, 1913. After extensive investigation and a number of meetings, the Committee on Social Insurance in the summer of 1914 issued a tentative statement of the essential lines it would follow in the drafting of a sickness insurance bill. Finally, in November 1915, with the- cooperation of a committee of the American Medical Association, the first tentative draft of an act for health insurance was published. A few months later the measure was introduced in the legislatures of New York, Massachusetts and New Jersey.-' This bill has come tO' be known as the "Standard Bill" and will be discussed later.^^ ™The president of the American association for 1918 is Samuel McCune Lindsay. The secretary is John B. Andrews of New York. The executive com- mittee, which is representative of its membership composed of labor leaders, em- ployers and scientific men, consists of : T. L. Chadbourne, Jr., lawyer, New York City; Henry W. Farnam and Irving Fisher of Yale University; Edmund N. Huyck, manufacturer, Albany, N. Y. ; V. Everit Macy, capitalist. New York City ; Royal Meeker, Chief of the United States Bureau of Labor Statistics, Wash- ington ; John Mitchell, former president of the United Mine Workers of America, Mount Vernon, N. Y. ; Margaret Dreier Robins, president of the National Women's Trade Union League of America, Chicago ; John A. Voll, president of the Glass Bottle Blowers' Association of the United States and Canada, Phila- delphia, Pa. " John B. Andrews, Address before il2(h Annual Meeting of the National Association for the Study and the Prevention of Tuberculosis, May, 1916. ^"The members of the Committee on Social Insurance that drafted this bill were: Miles M. Dawson, consulting actuary; Edward T. Devine, director. New York School of Philanthropy; Carroll W. Doten, secretary of the American Statistical Association ; S. S. Goldwater, formerly Commissioner, Department of Health, City of New York; Henry J. Harris, Chief, Division of Documents, Library of Congress ; Alexander Lambert, chairman of Social Insurance Com- mittee, American Medical Association; I. M. Rubinow, actuary and statistician; Henry R. Seager, Professor of Economics, Columbia University; Lillian D. Wald, head resident, Henry Street Settlement ; Jo'hn B. Andrews, secretary, American Association for Labor Legislation. 293 INVESTIGATING COMMISSIONS While in 1915 there were three legislatures in which the Standard Bill was introduced, there were, in 1917, twelve state legislatures that considered health insurance bills. Altogether, the legislatures of eight states have appointed commissions which have investigated the subject. The first commission to report was that of California, appointed in May 1915. While it was authorized to make a study of social insurance, it concentrated on health insurance. The commission, in its ref>ort to the legislature January 1917, was unanimous in favoring compulsory health insurance. The second commission to report was that of Massachusetts, cre- ated in 1916^. This commission investigated sickness, unemployment, old age and hours of labor. Its report, submitted in February 1917, endorsed the principle of health insurance unanimously. Five of the members favored the immediate adoption of compulsory health insur- ance of the type usually proposed. Two felt that there should be more investigation, while two more felt that if a compulsory system were adopted, the employee should not be required to contribute. New Jersey had appointed a commission in 191 1 to investigate old age insurance. This commission submitted a report in November 1917, stating its belief that "health protection should precede any provision for old age."^^ It, therefore, recommended the adoption of a health insurance measure, presumably compulsory. The commission felt that the need for such a measure was especially great at that time, because of the war situation. Meanwhile, Massachusetts had created another commission to con- centrate, this time, on health insurance. This second commission re- ported January 15, 191 8. Nine members voted against compulsory health insurance and two voted in favor of compulsory health insurance with no contributions from the employee. From a perusal of the report it would seem that the commission was concerned particularly with the problem of ascertaining the attitude of different interests. The report states than "an analysis of the evidence reveals no growing demand in the Commonwealth for compulsory contributory health legislation." At present, January, 1919, there are six commissions still at work which will report at the next meeting of the legislatures. They are: California (reappointed),, Connecticut, Illinois, Ohio, Pennsylvania and Wisconsin. The house committee authorized in New Hampshire has not been appointed. These commissions have held two national confer- ences, one in December 1917, at Philadelphia and one in May 1918, at Cleveland, to discuss problems and methods.^* '^ Report on Health Insurance by the New Jersey Commission, 1917, p. 4. ^* Reports of these conferences are contained in Vol. VIII, 1918, Nos. 1 and 2 of the American Labor Legislation Review, 294 It would seem that we have reached the same stage in health insur- ance legislation as was reached in accident compensation legislation nine years ago — the period of legislative investigating commissions. As yet no bill providing for compulsory health insurance has been passed.) BASIS OF AGITATION FOR COMPULSORY HEALTH INSURANCE It is not intended here to discuss the merits of the proposals for compulsory health insurance, but in order that the attitude of the dififer- ent interests may be properly understood, it seems advisable to state briefly the main, arguments which have been advanced pro and con: Underlying the agitation for compulsory health insurance is the belief that there exists an excessive amount of sickness ; that such sickness is one of the principal causes of poverty; and that existing agencies are inadequate either to prevent or distribute equitably the cost of such sickness. As evidence of the amount of sickness or disability prevalent, the report of the Provost Marshal General on the first draft under the selective service act in 1917, is cited. From this report, (pp. 44, 45) it is estimated that about 31 per cent of those registered were rejected as physically disqualified for service. The investigation made for the federal Commission on Industrial Relations by Dr. B. S. Warren and Edgar Sydenstricker, regarding industrial conditions and the public health, led to the conclusion that, among the thirty odd million wage- earners in the United States, there is annually an average of nine days a year lost through sickness, a total wage loss of $500,000,000 and a medi- cal cost of $180,000,000.-° Responsibility for sickness is generally attributed to three factors. The industry is held responsible for a certain portion, as indicated by the varying rates of morbidity and mortality for different occupations. The health hazard of some occupations (judging from the rate of insurance companies) is double that of the least hazardous occupation. The community is held responsible for the portion of sickness due to conditions under its control, such as housing, food, water supply, sewage disposal and the community environment in general. Such diseases as typhoid, scarlet fever, diphtheria and other epidemic diseases are clearly susceptible to community control. But it is impossible to go into a man's house and force him to observe the rules of personal hygiene, so that the individual is responsible for that portion of sickness due to failure to observe the rules of right living. Because of the joint responsibility of these three factors, all three are assessed, in most of the schemes proposed, a portion of the cost of compulsory health insurance. "Final Report of the Commission on Industrial Relations, 1915, p. 202. 295 The partnership of disease and poverty is considered by the advo- cates of compulsory insurance as a matter of common observation and the studies of infant mortality made by the Children's Bureau are pointed to as showing that the rate of infant mortality varies inversely with the family income. Likewise it is argued that the extra expense and the loss of wages caused by sickness often wipe out any surplus in the family budget and force the afiflicted family on charity. Devine states that of the destitute families coming under the care of the Charity Organization Society in New York City, three-fourths were found to be destitute wholly or partly on account of sickness.^' It is asserted that those who are sick, being unable to afford it, do not receive adequate medical attention. The health survey made by the City Club of Milwaukee states that 40,000 persons were sick at the time of the survey. Of these, 25,700 or 64.7 per cent would have been entitled to medical care under a compulsory health insurance bill such as the one introduced in New York and Massachusetts. Of those who would have been entitled to medical aid, only- 11,000 were under a doctor's care. On the other hand, the sickness surveys of the Metropoli- tan Life Insurance Company do not show such a large percentage of those sick without medical care. Their percentage of cases of sickness without medical attendance range from 24.2 per cent in Pittsburgh to 39 per cent in Rochester, N. Y.^^ It is contended by many who favor compulsory health insurance that contributions by the three factors responsible will distribute the burden equitably. It is claimed that the one who is sick will then be assured adequate medical attention and the family's income will not entirely cease, by reason of cash benefits to be provided. Advocates of compulsory health insurance believe that existing voluntary insurance carriers cannot take care of the problem, because not enough people are insured and those who are insured as a rule carry only enough insurance to provide funeral expenses. Studies made of family budgets show that a majority of families carry insurance of some sort. Chapin found, however, that the insurance was "not a provision for a rainy day, but a provision for meeting a single contingent expense; viz. the cost of burying the dead."^* Mrs. More found that "the insurance invariably goes to meet the expenses of the funeral or of the last illness.'"" "" E. T. Devine, Misery and Its Causes, 1910, p. 54. " See pamphlets issued by Metropolitan, Insurance Co. covering sickness sur- veys of Pittsburgh, Penn. ; Principal Cities in Pennsylvania and West Virginia; Chelsea Neighborhood, New York City; and Kansas City, Missouri; also reprints published by the United States Public Health Service of sickness surveys of North Carolina and Rochester, N. Y., made by officers of the same company. ^ R. C. Chapin, The Standard of Living in New York City, 1909, p. 192, ""I^ouise B, More, Wage-eqrners' B^dgets, '1907, p. 43, 296 It is also contended that the cost of voluntary insurance is ex- cessive, especially in the case of industrial insurance. The assertion is made regarding industrial accident and health ' insurance that only about one-third'" or two-fifths of the premiums are returned in the form of benefits to the insured. The excessive cost is considered inevitable because of the necessity of loading premiums to cover the necessary expense of securing and conducting the business. Under wholesale compulsory health insurance, it is believed that competitive and retail costs will be eliminated. Another advantage claimed for compulsory health insurance is that it will have a preventive effect. It is stated that, just as the number of accidents was reduced when workmen's compensation laws went into effect, so will the amount of sickness be reduced when the employer and the employee see that it pays to take precautions against sickness. The cost of health insurance is generally estimated as a percentage of the pay roll. The estimate usually given is 4 per cent. This cost varies directly with the benefits provided. Advocates of compulsory health insurance point out, however, that the costs are only made visible and distributed equitably. They contend that a rational method of carrier does not increase the cost, but may lighten it, as has been the case with workmen's compensation. Doctors have been paying in the form of charity work ; employers because of decreased output, due to worry and neglected cases of sickness among the employees ; employees through reduced earning power: and the whole community through contributions to charity and in increased amount of sickness. ARGUMENTS AGAINST COMPULSORY HEALTH INSURANCE The opponents of health insurance assert that the mortality and morbiHTty experience of this cotmtry is more favorable than that of Germany, the first country to adopt compulsory health insurance. "Thus, for Boston, Mass., the average sickness loss for males is only 6.3 days per annum, and for Rochester, N. Y., the loss is 7.0 days, against more than 9.2 days for Germany and 9.5 for Austria. "^^ It is also claimed that the mortality experience among'the industrial popula- tion is as favorable as that of the population at large. ''^ The increase in the amount of savings banks' deposits is offered as proof that wage-earners' budgets are sufficient to provide for proper medical care and the needs of dependents. Existing insurance agencies are considered adequate and more effi- cient than a state owned or controlled system. These voluntary agencies '^ I. M. Rubinow, Social Insurance, 1913, p. 296. " Frederick L. Hoflman, Facts and Fallacies of Compulsory Health Insur- ance, Prudential Press, 1917, p. 89. ^ Magnus W. Alexander, Some Vital Facts and Considerations in Respect to Compulsory Health Insurance^ Bulletin, March, 1917, p. 7, 297 are believed to encourage thrift and foster independence. It is also contended that prevention is not the function of insui-ance. Therefore, it is urged that public health administration and preventive medicine be developed instead. As positive objections to compulsory health insurance it is claimed that such a system is not in accord with our theory of government; that it is Prussianistic, socialistic or paternalistic in its nature; that it re- stricts personal liberty. It is also alleged that the moral effect on the workman will be bad and that it will lead to malingering. Finally it is urged that the status of the medical profession will be lowered, because of overwork, burdensome details, suppression of initiative on the part of physicians and insufficient remuneration. The following specific counter-suggestions have been made : 1. Development of state medical care to provide care for all. 2. Development of public health agencies. 3. Education in personal and public hygiene. 4. Development of institutional and group facilities for the treat- ment of disease — hospitals, dispensaries, diagnostic stations. 5. Compensation for occupational diseases. 6. Development of voluntary insurance carriers. 7. Development of institutions to encourage thrift. 8. Shorter hours, better pay and better conditions for labor. 1 THE STANDARD BILL The Standard Bill of the American Association for Labor Legis- lation, as published June, 1916, covers all manual employees and all other employees receiving less than $1,200 per annum. Home workers and casual workers may be included by administrative order. It provides benefits for all sickness, accidents and death not covered by workmen's compensation. The cash benefits are 66 2/3 per cent of the wages for a period not to exceed twenty-six weeks in any consecutive twelve months. The medical benefits consist of medical, surgical and nursing assistance and treatment; medicines and therapeutic appliances costing not more than $50 iri any one year ; hospital care ; medical and surgical treatment and medicines to dependents. Maternity benefits are provided for insured women and the wives of insured men, consisting of cash and medical benefits to the former and medical benefits to the latter. If hospital care is given the insured, the cash benefits are reduced to one-third of the wages. Funeral benefits up to $50 are allowed. Employers are obliged to contribute two-fifths, employee two-fifths and the state, one-fifth of the expenses. If the earnings of the insured are less than $9 a week, his contribution is reduced. Employees earning 298 less than $5 a week contribute nothing. In such cases the employet makes up the difference. The bill provides for the organization of local funds. In cities where there is a large enough number of employees in a' trade, trade funds are to be organized. Each of these funds is to be managed by a committee composed of representatives of employers and employees. This committee in turn elects a representative board of directors to carry out its policies. Non-profit making insurance carriers, such as fraternals, labor unions and establishment funds may come into -the system under rather discouraging conditions. The employer's contribution except in the case of establishment funds must be paid into a state guaranty fund, instead of to the society. If the operation of such a society endangers the exist- ence of a local or trade fund, it may be compelled to discontinue. Com- mercial insurance companies are excluded entirely. The medical service to be provided may be along either of the fol- lowing lines: 1. A panel of physicians to which all legally qualified physicians may belong, with freedom of choice of physician on the part of the insured. The number of insured persons on the list of any one physician may not exceed 1,000. 2. Salaried physicians in the employ of the carriers, with reason- able free choice of physician by insured. 3. District medical officers engaged for the treatment of insured persons in prescribed areas. 4. A combination of above methods. The method of compensation for medical service is not prescribed. Medical officers must be employed by the carriers to certify to claims and to supervise the character of the medical service. Arbitration com- mittees, both state and local, to be composed of the various interests, are provided to adjust disputes between the insured and the physician or between the fund and the physicians. There is to be a social insurance commission, one member of which shall be a physician, to carry out the provisions of the act. This commission is to be advised by a social insurance council, consisting of employer and employees. A medical advistory board, chosen by the state medical societies, is to( be consulted on medical matters and is to have the right to review disputes regarding medical matters which have been appealed to the commission.'^ The above bill is termed a "tentative draft" and has been modified in some respects. The bill as submitted to the Conference on Social "For more detailed information, see American Labor Legislation Review, Vol. VI, No. 2. 299 Insurance, December 19 16, was more specific.'* The medical organiza- tion is much more complete, due to the cooperation of the Social In- surance Committee of the American Medical Association. In addition to the local arbitration committees, there are created local medical committees, elected by the physicians. "To this committee come all the disputes in regard to medical benefit or any charge made against a physician because of his work, before it is sent on to the board of directors of the fund."^^ Public health officials are given a place both on the local medical committees and on the State Medical Advisory Board, so that the necessity for sanitation and preventive medicine may not be lost sight of. A state nurses' advisory board is also added. In all, the American Association for Labor Legislation has published HI 191 5 and 1916, three successive drafts of the Standard Bill, and as a result of further suggestions and deliberations by its Committee on Social Insurance, has adopted in lieu of a fourth tentative draft, the provisions of the Nicoll bill introduced in the New York legislature in 1 91 8 and discussed below. ' OTHER PROPOSALS The California commission, while it approved of the principle of compulsory health insurance, rejected two of the items in the plan of the Amercan Association for Labor Legislation. The commission be- lieved that only insurance for medical benefits should be in a prescribed carrier and that the cash benefits should be furnished by voluntary in- surance carriers. It also disapproved of placing the administration so largely in the hands of local committees, composed of employers and employees, believing that there would be too much friction and that there could be no assurance that the local officials possessed the neces- sary ability. The commission would still have state and local advisory boards, to allow for representation of interests. The administration, however, would be centralized in the state commission created to carry out the provisions of the law. Under the California plan, a state fund would be established, which would be practically the only carrier providing medical benefits, only trade and establishment funds being allowed to carry their own medical benefits. This fund would also provide cash benefits to those who cared to insure in it rather than in a voluntary association. Under this plan, the entire contribution to the state fund would be borne by the employers and the state. The medical organization under this scheme would consist of local panels, including all licensed physicians, under the supervision of district medical inspectors. "U. S. Bureau of Labor Statistics, Bulletin 212, 1917, p. 663. "/ttU, p. 647. 300 The Nicoll bill, introduced in the New York legislature in February, 1918, has been endorsed and widely distributed by the American Associ- ation for Labor Legislation in lieu of a fourth editiori of its tentative draft of a Standard Bill. This bill differs in some important particulars from the draft of the Standard Bill discussed above. This bill, which is fostered by the New York State Federation of Labor, excludes volun- tary insurance carriers (except establishment funds) from the system. This was not because the federation was opposed to voluntary insurance carriers, but because it believed that the system would operate more successfully, if these societies were allowed to supplement the com- pulsory system in furnishing additional benefits over and above those allowed under the compulsory system."" The Committee on Health appointed by the New York State Fed- eration of Labor felt that it would be difficult for the fraternal associ- ations and trade unions to rearrange their rates so as to provide the benefits required by the act. Consequently, they introduced the im- portant modification of a very low cash benefit to be paid under the compulsory scheme, so that opportunity might be left for fraternals and trade unions to furnish mainly the cash benefits, leaving the medical and hospital treatment to the compulsory system. Under this proposed arrangement, the functions of fraternals and trade unions would be the providing of additional cash benefits, while the compulsory' scheme would provide the minimum medical and cash benefits. In the Nicoll bill, the insurance is made compulsory for all em- ployees, the cash contribution by the state is eliminated and the contribu- tions by the employer and the employee are made equal. The decision to eliminate the contribution by the state is interesting, because some labor organizations object to any contribution on the part of the em- ployee. Of twenty-two labor representatives who testified before the Massachusetts Commission on Social Insurance, which reported January 15, 1918, all were in favor of some form of health insurance, but only '° Pamphlet, "Official Endorsement of New York State Federation of Labor,'' 1918. The Committee on Health to date has issued five reports : the one just referred to ; a second,, "Discussion of Bill Endorsed by New York State Federa- tion of Labor"; a third, "Advantages to Industry"; a fourth, "A Demand for the Passage of a Health Insurance Law" ; a fifth, "Progress Toward Health In- surance Legislation." The members of this committee are : James M. Lynch, formerly president of the International Typographical Union and now chair- man of the Industrial Commission of New York; William Rander, organizer for the Brotherhood of Painters and Decorators ; John M. O'Hanlon, member of the Troy Typographical Union; Charles H. Stevens of the Buffalo Cigar Makers; Richard H. Curran of the Rochester Holders; Nellie Kelly of the United Gar- ment Workers ; Rose Schneiderman of the Women's Trade Union League ; James P. Boyle of the Brooklyn Bookkeepers', Stenographers' and Accountants' Union; and Roswell D. Tompkins, secretary of the New York United Board of Business Agents. 301 one cared to go on record as favoring a contributory plan. The State Federation of Labor in Massachusetts also declared for a non-contribu- tory system. ATTITUDE OF ORGANIZED LABOR It will be seen that the New York State Federation of Labor has taken a definitely aggressive position in favor of a plan of compulsory health insurance, drafted by its own committee as a modification of the Standard Bill. Outside New York, organized labor has not studied the subject long enough to have committed itself definitely either for or against compulsory health insurance. The official attitude of indi- vidual unions, as expressed in the form of resolutions, sometimes de- pends upon the opinion of whoever happened to present the resolution. Not being immediately concerned with the subject, the resolution may be passed without close scrutiny. A case in point is that of the Inter- national Typographical Union. At its Scranton meeting, in August, 1918, two conflicting resolutions were introduced. The first resolution favored the inclusion of occupational diseases in workmen's compen- sation laws (proposition 72) but was opposed to health insurance, say- ing: the system of health insurance is advocated mainly by socialists and theorists, who, for the most part are not affiliated with, the labor movement. The second resolution favoring health insurance (proposition 118) was adopted later in the session and carried this clause : Resolved, That the Scranton Convention of the International Typographical Union herewith endorse health insurance for wage-earners and their dependents, with equal contributions from employers and employees, the funds democratically administered. T)ie Executive Council of the American Federation of Labor has been distinctly opposed to comptilsory health insurance, but has favored investigation of its merits." This appears from the annual reports made by the council to the annual conventions of the federation. In 1915, the report contained the following clause -.^^ We strongly recommend that the subject of social insurance in all its phases be given greater consideration and extension by the unions and preferentially by the national and international unions, as well as by the local unions, and in any "' The Executive Council is elected at the annual conventions of the Amer- ican Federation of Labor, and for the year 191748 was composed as follows: Samuel Gompers, Jdmes Duncan, James O'Connell, Jos. F. Valentine, John R. Alpine, H. P. Perham, Frank Duffy, William Green, W. D. Mahon, Daniel J. Tobin, Frank Morrison. At the convention in 1918 T. A. Rickert and Jacob Fischer were substituted for James O'Connell and H. P. Perham. '^ Report of the Proceedings of the 36th Annual Convention of the American Federation of Labor, Baltimore, 1916, p. 14.5^ 302 event, in so far as social insurance by the state and national governments is con- cernedj if established at all, shall be voluntary and not compulsory. In its report to the convention at St. Paul in June, 1918, the Executive Council made the following comment and recommendation:^" The organized labor movement approved the enactment of workmen's com- pensation legislation. Their approval of that legislation was based upon the theory that when the earning power of a worker was impaired by reason of an industrial accident, that he or his dependents should be compensated during the time he was suffering from said injury. The same rule holds good when the worker becomes incapacitated thi-ough illness — particularly illness due to trade or occupation. He and his family suffer through the impairment of his earning power just the same when he is ill as when he sustains an injury. The organized labor movement of America ought to formulate a program upon this subject. We therefore recommend to this convention that it authorize the Executive Council of the American Federation of Labor to make an investigation into the subject of Health Insurance, particularly as it applies to trade or occupational disease. If approved a model bill be formulated and reported to the A. F. of L. for approval. We urge that as part of such legislation there should be embodied fundamental principles of democratic administration and guarantee to the workers of an equal voice and equal authority in the administration of all its features. It was decided that the Executive Council recommend to the convention that it authorize the Executive Council to appoint a committee to make a study and report on the desirability of enacting laws providing for the payment of sick benefits during time of illness. The annual convention of the American Federation of Labor is composed of delegates from the national and international trade unions and from state federations and certain local labor federations. The number of delegates in 1918 vi^as 448. At the Baltimore convention, 1916, the convention unanimously approved the recommendation of its Executive Council, as quoted above, in opposition to compulsory social insurance. It also passed this resolution :*° 'Resolved, That the American Federation of Labor in Thirty-sixth Annual Convention assembled, declares against private insurance or insurance for profit, as it may apply to industrial, social or health insurance. At the convention in 1918 a resolution introduced from the floor and approving "a comprehensive national system of social insurance" was voted down on the ground that it did not provide for the investiga- tions which "should necessarily precede a definite conclusion or program on the subject." The convention, at the same time, approved the recom- " Report of the Proceedings of the sSfh Annual Convention of the American Federation of Labor, St. Paul, 1918, p. 94. "Report of the Proceedings of the 36th Annual Convention of the American Federation of Labor, Baltimore, 1916, p. 216. \ \ 303 \ tnendation of the Executive Council above quoted, and instructed the council to make the investigation.*^ Through inquiries made "by correspondence with the secretaries of labor organizations, it has been found that the following national and international unions have placed themselves on record as favoring com- pulsory health insurance : Brotherhood of Railway Carmen of America ; International Brotherhood of Pulp, Sulphite and Paper Mill Workers of the United States and Canada; International Fur Workers' Union of the United States and Canada; International Stereotypers' and Elec- trotypers' Union oi- North America; International Union of Steam and Operating Engineers; International Union of Mine, Mill and Smelter Workers; International Typographical Union; National Women's Trade Union League. In addition to these, the New York State Federation of Labor reports the following national and international unions as favoring compulsory health insurance:*^ American Wire Weavers' Protective Association; National Brotherhood of Foundry Employees; International Glove Workers' Union of America; Spinners International Union; Retail Clerks' International Protective Association. Correspondence with the secretaries of state federations of labor furnishes the following list as favoring compulsory health insurance : The state federations of labor in California, Colorado, Indiana, Louisi- ana, Massachusetts, Minnesota, Missouri, New York, Pennsylvania and Wisconsin. The New York State Federation of Labor reports these additional state federations as favorable to compulsory health insur- ance:*^ state federations of labor in Alabama, Connecticut, Maryland- District of Columbia, Illinois, New Jersey, Ohio and West Virginia. Whatever opposition to compulsory health insurance exists on the part of organized labor arises partly from the belief that such a measure might undermine union activity and prove to be only a palliative and a substitute for better wages, hours and conditions of labor. Thus, Samuel Gompers, president of the American Federation of Labor, has said :" This fundamental fact standi out paramount, that social insurance cannot' remove or prevent poverty. It does not get at the cause of social injustice. -.■ . The efforts of trade organizations are_ directed at fundamental things. They endeavor to secure to all the woirkers a living wage that will enable them to have "Report of the Proceedings of the 38th Annual Convention of the American Federation of Labor, St. Paul, 1918, p. 283. The special committee to investigate health insurance has recently been appointed with John A. Voll, president of the Glass Bottle Blowers' Association, as chairman. ' *" See p. 15, First Report of the Committee on Health, and p. 6, Fifth Report of the same committee. " See p. 15, First Report of the Committee on Health, and p. 6, Fifth Report of the sarne committee. "Address at the 17th Annual Meeting of the National Civic Federation, Jan. 22, 1917. 304 sanitary homes, conditions of living that are conducive to health, adequate cloth- ing, 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 infinitely more than any health insurance could do which- pro- vides only for relief in case of sickness, and yet the compulsory law would under- mine union activity. There would necessarily be a weakening of independence of spirit and virility, when compulsory insurance is provided for so large a number of citizens of the state. ATTITUDE OF EMPLOYERS In addition to the general arguments before mentioned, employers have pointed out that the initial expense of insurance could not be absorbed in the cost of production and shifted to consumers. They also feel that, if such a law is not uniform throughout the United States, it will place employers in states which adopt it at a disadvantage in competition with those of other states. The Associated Manufacturers and Merchants of New York State, with headquarters at Bufifalo, are conducting a strong fight against it in that state. Their arguments- are presented in a monthly bulletin, the Monitor. The National Industrial Conference Board, headquarters at Boston, composed of national associations of employers,*^ has issued! a series of pamphlets tending to show that sickness prevention rather than sickness insurance is the thing to be desired. It has had representatives at various legislative hearings and in California during the recent referendum on the proposed social insurance amendment to the constitution. The Illinois Manufacturers' Association in a memorandum ad- dressed to the Commission on Health Insurance of the State of Illinois set forth their' position as follows: We respectfully submit that the responsibility and cost of illness among those employed in industry should be apportioned as follows : 1. The cost of disability due to strictly occupational diseases should be borne entirely by the employer and the amount and manner of^ compensation may properly be fixed by the Workmen's Compensation Law. 2. If Illinois sees fit to adopt a program of Social Insurance, then the por- tion of the cost which the beneficiaries themselves cannot bear may possibly be assumed by the citizens and taxpayers of the state, but no employer should be assessed therefor in any greater degree than he would be for any Other burden that falls generally upon the community. ■"* Members : American Cotton Manufacturers' Association ; American Hard- ware Manufacturers' Association; American Paper and Pulp Association; Elec- trical Manufacturers' Club; Manufacturing Chemists' Association of the United States; National Association of Cotton Manufacturers; National Association of Manufacturers; National Association of Wool Manufacturers; National Auto- mobile Chamber of Commerce ; National Boot and Shoe Manufacturers' Asso- ciation; National Council of Industrial Defense; National Erectors' Association; National Founders' Association; National Metal Trades' Association; Rubber Association of America, Incorporated; Silk Association of America; United Typothetae of America. 30S The National Association of Manufacturers has not taken any posi- tive action for or against compulsory health insurance, although it has had a committee investigating the subject since 1915. At its annual convention in that year it approved of the appointment of a Committee on Industrial Betterment, to study the problems of social legislation; particularly, the questions of the minimum wage, insurance against sick- ness and unemployment. This committee stated in its 1916 report that "sickness insurance should be made to cover workers independent of whether the cause of the sickness arose out of, or in the course of employment." The report also stated that, "The plan must contain the elements of compulsion, .direct or indirect, as a matter of expedi- ency in securing the acceptance of the act."*" The Committee on Industrial Betterment for the year 1916-1917 had a slightly dififerent personnel, William P. White replacing F. C. Schwedtman, as chairman. Its report at the 1917 convention carried the following paragraph:*^ Your Committee is not convinced from its study of the available data on the subject that the creation, establishment, and operation of a state-governed system of compulsory sickness insurance is either necessary, wise, or desirable. The report of the Committee on Industrial Betterment for 1917- 1918 contained the following statements :*' Sickness is not only a problem for the community as a whole, to be treated as an administrative function of the state, but it is also a problem arising out of industry. It would seem to your Committee that, prior to the consideration of a com- pulsory form of industrial sickness insurance, the question of voluntary insur- ance sbould be carefully reviewed, especially the study of existing systems in operation in . many of our industrial and transportation companies. The Massachusetts Commission on Social Insurance has declared itself to be "unanimously of the opinion that the principle of insurance is a desirable one for application on a sufficiently wide scale to safeguard every wage-earner in the Commonwealth from certain of the evils of sickness. ." With this principle your Committee thoroughly agrees, for insurance is the proper method to distributei rtihe losses of sickness, and is so generally recognized. We hazard the opinion that unless sickness insurance is democratically ad- ministered, equitably worked out, and extended to cover practically all kinds of wage workers, there will be enacted into law compulsory sickness insurance — a proceeding which your Committee at the present time feels would be some reflec- tion on the high standards of industrial conduct wbich characterize the safe- guarding of American workers. "Proceedings of 21st Annual Convention of the National Association of Manufacturers, 1916, pp. 33-39. "Proceedings of the zznd Annual Convention of the National Association of Manufacturers, 1917, p. 21. "Proceedings of the 23rd Annual Convention of the National Association of Manufacturers, 1918, pp. 162-164. 20 3o6 None of the above reports were adopted; they were accepted and ordered printed. ATTITUDE OF MEDICAL PROFESSION The Board of Trustees of the American Medical Association ap- pointed in January, 1918, a special committee to investigate social insur- ance. This committee issued a series of pamphlets, dealing chiefly with health insurance. In June, 1917, the House of Delegates of the Amer- ican Medical Association passed a resolution encouraging further work on the subject and instructing its Council on Health and Public Instruc- . tion to cooperate when possible "in the molding of these laws that the health of the community may be properly safeguarded and the interests of the medical profession protected" and to "insist that such legislation shall provide for freedom of choice of physicians by the insured ; pay- ment of the physician in proportion to the amount of work done; the separation of the function of medical official supervision from the func- tion of daily care of the sick ; and the adequate representation of the medical profession on the appropriate administrative bodies." This resolution, it will be noted, is neither for nor against compul- sory health insurance and is the only resolution on the subject ever passed by the House of Delegates of the American Medical Association. The medical organization proposed in the Standard Bill is in harmony with this resolution. This would necessarily be so, since the Committee on Social Insurance which presented the resolution to the medical asso- ciation for approval was represented by Dr. Alexander Lambert on the committee of the American Association for Labor Legislation which drafted the provisions of the Standard Bill. At the second annual meeting of the American Association of Indus- trial Physicians and Surgeons in 1917, including mainly members of the profession employed by corporations, the report of the Committee on Health Insurance which stated 'that the principle of health insurance which makes proper provision for the prevention of sickness as well as proper provision for the relief of sickness is a sound one" was unan- imously adopted.' This resolution had reference to compulsory health insurance. Public health physicians, while they seem generally to favor the establishment of government systems of health insurance, believe:^" That in any scheme for health insurance, all activities looking towarS the active conservation and promotion of health should be entrusted to the reg=Hlarly established health conservation agencies, which should be reorganized or rein- forced for that purpose, if necessary. "Resolution adopted at the 15th Annual Conference of State and Terri- torial Health Officers with the U. S. Public Health Service, 1917. 30/' Dr. B. S. Warren, of the United States Public Health Service, would have the state health commissioner made a member of the health insur- ance commission. He would also have the referees who supervise the medical benefits in the employ of the health department. It is doubtful whether the medical profession would submit to this control. As with the physicians, all the other interests affected — -nurses, dentists, druggists, oculists, and hospitals • — demand that they shall be represented. The public health nurses do not object to the scheme, if we may take as representative the sentiments expressed by Mary Beard, president of the National Organization for Public Health Nursing : "We public health nurses have more conclusive evidence than any other group in America [of the need of health insurance] . . . Health insurance is advancing more and more certainly.''^" The American Hospital Association at its meeting, September 27, 1918, adopted this resolution : Resolved, by the American Hospital Association that the importance of health insurance investigation be recognized by this body and the Board of Trustees be directed to make a study of the subject in its relation to the hos- pitals and dispensaries ; that the Board of Trustees give such assistance as may be requested in the formulation of plans and of legislative bills ; that the members of this Association and the State Hospital Association be urged to give the sub- ject careful study and to cooperate wherever possible in the effective solution of the problems unsolved. ATTITUDE OF DRUGGISTS In as much as compulsory health insurance will mean more or less wholesale distribution of drugs, it would be expected that druggists would not take kindly to the plan. The American Pharmaceutical Association passed the follow resolution at its 1917 convention : The American Pharmaceutical . Association desires to express its disap- proval of the Compulsory Health Insurance Bills introduced in different state legislatures during the past winter. It is quite likely that, in the interests of wage-earners of very limited income something in the way of social insurance should be provided under the supervision of the state, but the present plan goes much too far and is open to many vital objections. The National Association of Retail Druggists at its 1918 convention passed this resolution : Whereas, the proponents of compulsory health insurance continue their activities in an effort to force such a measure upon the people of the several states, and Whereas, we believe such Prussianized legislation to be inimical to the practice of pharmacy; therefore be it Resolved, Ithat the National Association of Retail Druggists be and hereby is requested to reiterate its opposition to such obnoxious measures and to lend "Quoted in the Fifth Report of the Committee on Health of the New York Federation of Labor. 3o8 its assistance to the pharmacists of the various states in their efforts to prevent the enactment of compulsory health insurance laws. The "floating six-pence" of the British health insurance act, a plan whereby the physicians' fund benefits by reduction in the amount of drugs prescribed, is responsible for much of the hostile feeling on the part of druggists. ATTITUDE OF INSURANCE COMPANIES The interest most deeply affected adversely by compulsory health insurance would be the commercial insurance company. The majority of labor organizations that have gone on record as favoring health in- surance, declare themselves opposed to commercial insurance carriers. The plan submitted by the American Association for Labor Legislation likewise excludes the commercial insurance carriers. The industrial insurance companies would suffer most of all, since they in reality supply what amounts to burial insurance, The "Insurance Year Book" for 1918 states that industrial insurance companies have issued 38,373,272 in- dustrial policies in the amount of $5,193,830,295. The average policy is therefore about $138. The casualty companies would be affected somewhat, but their business is not so directly connected with wage- earners. The commercial insurance companies are conducting a well organ- ized and extensive propaganda against compulsory health insurance. Perhaps the most effective opponent of compulsory health insurance is Dr. Frederick L. Hoffman, statistician and third vice-president of the Prudential Insurance Company. His pamphlet, "Facts and Fallacies of Compulsory Health Insurance" published by the Prudential Press, Newark, N. J., has been widely distributed" and forms a large part of the arguments and statistical data of the opponents of compulsory health insurance. P. Tecumseh Sherman, New York attorney and former Commis- sioner of Labor of that state, has issued a pamphlet, "Criticism of a Tentative Draft of an Act for Health Insurance." Mr. Sherman fre- quently appears at legislative hearings as counsel for insurance com- panies. The fraternal insurance associations also feel that their interests would suffer. At the National Fraternal Congress of America in August 1918, it was resolved "That the constituent societies of the Congress use all honorable means to prevent the enactment into law in any form of a plan for social insurance through state or national control." Other propaganda agencies supporting the insurance companies are : The Workmen's Compensation Publicity Bureau (New York), The In- surance Economics Society of America (Detroit), and the California Research Society of Social Economics (Los Angeles). 309 ATTITUDE OF OTHER INTERESTS AFFECTED Most of the foregoing discussion has been confined to an analysis of the attitude of the major interests directly affected. However, there are some groups and associations, representing interests indirectly af- fected or which are more or less detached interests, which should be mentioned. The majority of charity workers seem to favor compulsory health insurance. Eugene T. Lies, until recently superintendent of the United Charities, Chicago, believes "Health insurance would bring to wage- earners prompt medical care, cash benefits to tide them and give them an early chance for recovery, all for a small insurance premium. "^^ J. W. Magruder, general secretary of the Federated Charities, Baltimore, Md., says, "The charity organizations, however, will be the more able to accept the responsibility for the relatively small group of unfortunates [not covered by health insurance].""^ The socialists' claim to be the first political party in this country to adopt a compulsory insurance plank. ^' The Social Democratic Party in '^Proceedings of National Conference of Social Work, p. 552. ■"U. S. Bureau of Labor Statistics, Bulletin No. 212, p. 636. ^Editor's Note. The movement has spread to the parties in power. In Massachusetts where two state commissions have studied health insurance the Democratic Party in 1916 declared in favor of health insurance and the Repub- lican Party favored a careful investigation. Three times Governor McCall in his gubernatorial message has brought health insurance to the official attention of the legislature. In 1917 he declared: I am strongly of the opinion that there is no form of social insurance that is more humane, sounder in principle, and that would confer greater benefit upon large groups of our population and upon the Commonwealth as a whole than health insurance. — I recommend that you establish a compulsory system with a reasonable benefit during the period of sickness, and that the system be made to include members of the family. In 1918 under the stress of war emergency Governor McCall again recom- mended health insurance legislation, saying: A great amount of this staggering loss and the resulting expense might be averted by prompt and adequate medical care, such as a well-organized system of health insurance would supply, and such as it does supply in those countries which have established such a system. As I have said, general legislation should at the present session be undertaken with unusual caution. But the care of the workers has a very special reference to our efficiency in war. — A comprehensive system which would so far as possible do away with the waste resulting from accident and sickness would be a wise,- humane and beneficent measure. . . I believe firmly in the wisdom and justice both- of health and of old age insurance, and of the inevitableness of their coming. Very much is to be said in favor of both even in war time, and especially in favor of the immediate conservation of the health of our workers. (Address of His Excellency Samuel W. McCall to the Two Branches of the Legislature of Massachusetts, January S, 1918.) The war emergency over Governor Smith of New York in January, 1919, included recommendation for health insurance legislation in his message to the legislature, saying: The incapacity of the wage-earner because of illness is one of the underlying causes of poverty. Now the worker and his family bear this burden alone. The enactment of a health insurance law, which I strongly urge, will remedy this unfair condition. Moreover, it will result in greater precautions being taken to prevent illness and disease, and to eliminate the consequent waste to the State therefrom. — Proper provision also should be made for maternity insurance in the interest of posterity and of the race. 310 1900 had a plank providing for "National Insurance of working people against accident, lack of employment and want in old age." The 1904 platfoi-m of the Socialist Party carried a plank "for the insurance of the workers against accident, sickness and lack of employment; for pensions for aged and exhausted workers." The 1908 plans added death insurance. The 1912 and 1916 platforms had the following provisions ; A general system of insurance by the state of all its members against unem ployment and invalidism and a system of compulsory insurance by employers of their workers without cost to the latter, against industrial diseases, accidents and death. The Progressives were the second national party to endorse health insurance, declaring in the 1912 platform for : The protection of home life against hazards of sickness, irregular employ- ment and old age through the adoption of a system of social insurance adapted to American use. The Christian Scientists are opposed to compulsory health insurance because they believe it is unjust to compel them to contribute toward the support of a system which is repugnant to their religious beliefs and from which they can receive no benefit. They played an influential part in the defeat of the California constitutional amendment. The National Consumers' League at its recent meeting in 1918 passed the following resolution : Whereas, the war-time experience of women as wage-earners taking the places of men has greatly emphasized the need of compulsory health insurance ; therefore be it Resolved, that the National Consumers' League endorse in principle the prompt passage of health insurance by the state legislatures. The National Civic Federation, which is designed to represent organized labor, organized industry and the general public, began in 1913 what was expected to be a five year investigation of social insurance in this country and abroad. The Committee on Preliminary Foreign Inquiry, a sub-committee of the Social Insurance Department, submitted a report in 1914 covering the operation of social insurance in England. Further foreign investigation was cut short by the war. The report on England on the whole was unfavorable and the committee concluded "that the entire movement as it has thus far advanced in England " is still too young to afiford any permanent conclusions upon its human or social economic values." The members of this committee were: J. W. Sullivan, representing the American Federation of Labor; Arthur Wil- liams, representing employers ; P. Tecumseh Sherman, attorney and social insurance specialist. Mr. Sherman has been mentioned before as author of a pamphlet criticizing the Standard Bill and as an attorney representing insurance companies. 3" The Social Insurance Department of the National Civic Federation on February 20, 1917, published the following resolution : Resolved, that the Social Insurance Department of the National Civic Federation, composed of representatives of organized labor, organized industry and the interests of the general public, emphatically declare itself opposed to the contemplated legislation with reference to compulsory health insurance, as inimical to the best interests, present and future, of the workers of the nation." A month before this resolution was adopted the annual meeting of the National Civic Federation had been held under the auspices of the Social Insurance Department. At this meeting, which was devoted to, compulsory health insurance, all of the addresses with the exception of those descriptive of establishment funds, were in opposition. THE CALIFORNIA REFERENDUM At the last election (November, 1918) the:re was submitted to the people of California for a referendum vote an amendment to the state constitution, which was designed to give the legislature power to pass social insurance legislation. This amendment had been offered by the Social Insurance Commission whose report has already been mentioned above. The amendment failed of passage by a vote of more than two , to one. The Christian Scientists are said to have been a potent factor in bringing about this result. In addition to the opposition of Christian Scientists, the fraternal and commercial insurance companies assisted in defeating the amend- ment. Some of the large fraternal organizations sent a personal com- munication to each of their members, asking that they vote against the amendment. In this way over 200,000 voters are said to have been reached. The Associated Fraternal Societies of California also issued literature under the auspices of the California Research Society of Social Economics, which has already been mentioned as one of the propaganda agencies supporting the commercial insurance companies. " See statement issued by Social Insurance Department, Reprint May 26, 1917, prepared by the Legislative Committee, composed of Lee K. Frankel, third vice-president of Metropolitan Life Insurance Co., chairman ; A. Parker Nevin, National Association of Manufacturers ; Hugh Frayne, American Federation of Labor. The chairman of the Social Insurance Department is Warren S. Stone, grand chief. International Brotherhood of Locomotive Engineers. APPENDIX B HEALTH INSURANCE IN GREAT BRITAIN Edith Abbott Lecturer in Sociology, University of Chicago, and Associate Director, Chicago School of Civics and Philanthropy The national insurance act was introduced into Parliament by Mr. Lloyd George, then Chancellor of the Exchequer in Mr. Asquith's cabi- net, on May 4, 191 1. After prolonged debate and repeated changes, it finally became a law on December 16, 191 1, and Went into operation July 15, 1912. The act was amended in 1913 and again in 1918, and four special amendments affecting the men in the army and navy were passed between 1914 and 19x7. These four war amendments will be disregarded for the purposes of this discussion since they were made necessary by the abnormal conditions of the times, when a large pro- portion of the insured male population of the country had left their ordinary employments to serve with the British forces. Health insurance had been promised by the Liberal party in 1908, and during the three following years Mr. Lloyd George and the govern- ment actuaries had been at work formulating plans for a scheme that would be practicable in Great Britain. At the outset it was found neces- sary to depart from the non-contributory principle which Parliament had adopted for old age pensions. It is, perhaps, the contributory feature of the plan which has led to the charge that the British health insurance act was "made in Ger- many" and that Great Britain had copied the German scheme. As a matter of fact this charge was of no importance before the war. So different, indeed, was the English from the German scheme that the statement was made in the House during the debate on the bill, that "the Chancellor of the Exchequer, in framing his industrial insurance scheme, has evidently gone to Germany not so much for example as for knowledge of what to avoid." The English scheme is much more gen- erous and democratic than the German measure. It is generous in the large contribution made by the state, generous in its special provision for the low wage-earner, generous in its provisions as to arrears, and democratic in its administration. The Adoption of the Contributory System in England. Health insurance in England appears to have been made contribu- tory solely because the government could not see its way to financing a (312) 313 non-contributory scheme. The old age pension system, which was non- contributory, was exceedingly popular; but the cost had risen to the large sum of thirteen million pounds per annum (approximately $63,- 000,000) and to add the entire cost of health insurance to the budget was admitted to be impracticable even by the leaders of the Labor party. The contributory principle appears to have been accepted reluctantly, since the Chancellor and the Prime Minister were both on record as opposed to financing social reform measures on a contributory basis. In 1908, Mr. Asquith had said in the House: The German system . . . could not be translated here for one simple and sufficient reason, that it is founded on the two pillars of inquisition and compulsion. Whatever the honorable member for Preston may think, you can- not brigade the industry, you cannot, if you would, set up and work here the complicated and irritating machinery by which in Germany the necessary funds for a provision against sickness and old age are extracted from the profits of both employer and employed. Mr. Lloyd George, too, in speaking during the old age pensions debate had declared that he had no use for the terms "contributory" and "non-contributory." So long, he said, as taxes were imposed upon the commodities consumed in every family in the land, every family in the land was actually contributing to the pension (or insurance) fund. When a scheme is financed out of publio' funds, it is as much a contributory scheme as a scheme which is financed directly by means of contributions ar- ranged on the German or any other basis. A workman who has contributed health and strength, vigor and skill, to the creation of wealth by which taxation is borne, had made his contribution already to the fund which is to give him a pension when he is no longer fit to create that wealth. Nevertheless in practice, Mr. Asquith and Mr. Lloyd George found it necessary to adopt a contributory system when they faced the necessity of finding money to pay for health insurance, in addition to old age pensions. A bitter attack on the contributory principle by Mr. Philip Snowden'- (Socialist and Labor member) brought from Mr. Lloyd ' Mr. Snowden (Hansard Parliamentary Debates, Vol. 26, c. 13&3) said : "I am opposed altogether to the principle of contributions. A contributory scheme is costly, cumbersome and irritating. . Such a contributory scheme . . . is against the tendency of all recent legislation. The practice of requir- ing a direct contribution for social services has been gradually abandoned during the last thirty years, because it was both expensive and ineffective . . work- ing people cannot afford to pay the contribution which is to be expected from them under this bill. . We began forty years ago by imposing a direct contribution on the parents of children to pay for the education of their chil- dren, and it took thirty years of agitation to get rid of it. The principle of state financial responsibility is embodied in nearly all recent legislation — in the Workmen's Compulsory Insurance Acts, in Public Health Acts, and even in the old age pension legislation," 314 George the reply that the theory that the whole of the burden ought to be cast upon the state was an intelligible point of view that could be defended "except by those responsible for raising the money. . . . You cannot raise taxation in this country without exciting every inter- est." In general the Labor members of the House of Commons acquiesced in the necessity of contributions, and a specially convened Labor con- ference which met in Coronation Week (June, 191 1) supported a con- tributory scheme but objected to the size of the workers' contribution. A typical expression of Labor opinion came from Mr. Barnes, who said that he believed the coinpulsory deduction from wages was "theo- retically unsound," and ''workmen have hitherto been very chary about accepting deductions from wages, and rightly so." "The state," he said, "ought to bear these burdens. But we are willing to face facts." Mr. Ramsay MacDonald, chairman of the Labor party, speaking in the House of Commons during the debate, cordially approved the bill and accepted the contributory basis of the scheme as necessary and proper. "The bill was welcomed," he said, "very heartily and most sincerely" by the Labor party, and the proposed scheme represented a fundamental change in public opinion, "one of those advances which one finds in public opinion happening periodically about once every century." On the whole the Labor leaders, opposed though they might be to the contributory principle, preferred health insurance with con- tributions from the workers to no insurance at all. It is only fair, before outlining and criticizing the act, to note that Mr. Lloyd George said more than once in the course of the debate that he was really proposing only an initial measure, a beginning of a much needed social reform, which would require finally much more sweeping social changes than could immediately be brought about. "I do not pretend," he said emphatically, "that this is a complete remedy. Before you get a complete remedy for these social ills you will have to cut in deeper. . . . Meantime," he added, "till the advent of a complete remedy, this scheme will alleviate an immense mass of human suffering. . . . Something like 15,000,000 people will be insured at any rate against the acute distress which now darkens the homes of the workmen whenever there is sickness and unemployment." PART I: PROVISIONS OF THE HEALTH INSURANCE ACT Scope of the Act. Health insurance is compulsory upon all persons in Great Britain and Ireland from sixteen to seventy years of age who are employed at manual labor and upon all other employed persons whose rate of re- muneration is not in excess of ii6o ($778.64) per annum. There are a few exceptions such as teachers for whom benefits are provided under 3IS a sUt)erannuation scheme, and certain public employees and employees of statutory companies where the terms of their employment are such as to secure provision in respect of sickness and disablement benefit not less favorable than those provided by the act. Exemption from the act is also provided for certain persons such as those not mainly dependent upon" their own earnings. But the act is wide in its scope. Home workers are included under it, and even such irregularly employed work- ers as dock laborers and golf caddies. On the other hand, all per- sons working on their own account such as small shopkeepers and peddlers, who form a large class, are not brought under the act except as voluntary^ contributors. The number of persons insured in February, 1914, was 13,759,400 ; of this number 9,682,300 were men and 4,077,100 were women. Com- paring the number of insured persons with the estimated population between sixteen and seventy years of age, there appear to have been in England approximately 57 per cent of the adult male population insured and 22 per cent of the adult female population insured. The Insurance Fund It has already been said that the British insurance act is a con- tributory scheme. The fund from which benefits are paid is derived from joint contributions of the employers, the insured wage-earners and the state. The contributions are divided as follows: in the case of the men, the state contributes two-ninths, the employers three-ninths and the men themselves four-ninths. In the case of the women, the state contributes one-fourth of the sum and the remainder is divided evenly between the working woman and her employer.. The actual contribu- tions per week are as follows: 4(7'. (8 cents) from the employed man and 3(i. (6 cents) from the employed woman; ^ the employer contributes 3d. (6 cents)i in either case; and the state 2d. (4 cents) in either case. The contributions are uniform for all grades of labor with a single exception, which will presently be noted. The employer must pay a contributions even for employees who are themselves exempt from con- 'tributing. This is done in order that exempt persons may not be "The subject of voluntary insurance for which provision is made under the act, with certain limitations, is omitted from this discussion. "In Ireland ithe normal weekly contribution from insured men is 3d. (6 cents) a week and from insured women only 2d. (4 cents). This is due to the fact that in Ireland a free state medical service has been provided since the year 1851, and therefore it was not necessary to provide medical benefit under the act for Irish contributors. There are in Ireland 840 dispensary districts, in each of which there is a "dispensary doctor'' who is the local public health officer as well as the salaried public medical attendant. Although the doctor is supposed to attend only "poor persons," as a matter of fact, dispensary tickets are given away freely and are used by the shopkeepers and small farming class as well as by weekly wage-earners. 3i6 specially sought after by employers to the injury of other workers. The German "class system" of contributions and benefits was rejected on the ground that, if these were varied in accordance with variations in wages, the lower paid wage-earners would receive very inadequate bene- fits. Mr. Lloyd George, speaking in the House of Commons in 191 1, said that he had not adopted the German system because in the lower classes . the benefits are so small that the workmen in Germany say they prefer to resort to parish relief as the benefits are much too inadequate. For that reason we have decided in favor of one class, because if you have a scale which is proportionate it would certainly not give them [the lowest class] a minimum allowance to keep their families from want (Hansard, v. 25, c. 616). The British Insurance System Non-contributory for Persons Earning Low Wages From the beginning it was planned to make special provision for those receiving very low wages. When Mr. Lloyd George introduced his bill, he said that the flat rate system of contribution would have to be modified for persons earning abnormally low wages. In such cases the contribution of the insured person was to be reduced and the differ- ence was to be paid not by the state but by the employer. In the words of Mr. Lloyd George: If you make the state pay the difference, then it means that the employers who pay high wages to their workmen will be taxed for the purpose of making up the diminished charge for workmen of other employers who are paying less. . . . We have come to the conclusion that the difference ought to be made up by the employer who profits by cheap labor, and therefore in the lowest case (in the case of 15s. a week and downwards) the employer will pay more. . . . Our scale of deduction for the workman is a uniform one with the exception of that descending scale when you come to the very lowest wages and where you really cannot expect a man to pay id. a week. As a matter of fact, it was finally provided that for those in the very lowest wage class, insurance was to be non-contributory and con- tributions were to be reduced in other classes as follows : Group I. Persons over 21 years of age earning not more than IS. 6d. (37 cents) a day. Groups. Persons over 21 years earning from u. yd. (39 cents) to 2 J. (49 cents) a day. Group 3. Persons over 21 years earning from 2s. id. (51 cents) to 2s. 6d. (61 cents) a day. Fo.r group i insurance is made non-contributory so far as the wage- earner is concerned. The state contributes an extra weekly penny in such cases and the employer is made to contribute an additional 3d. for the insurance of adult males and an additional 2d. for the insurance of 3i; aduit females employed at such low wages. In group 2 the wage-earner contributes only .a penny weekly, the state contributes an extra penny and the employer's contribution is increased by 2d. (4 cents) a week for men and id. (2 cents) a week for women employed at these low rates. In group 3 there is no extra contribution by the state, but the male wage- earners in this class have their contributions decreased by one penny while their employers' contributions are increased at the same rate. Machinery for Collecting Contributions The contributions of employers and workmen are collected by means of special insurance stamps which can be purchased at the post office. Every employed person, man or woman, is given a card; and at the end of the week the employer puts on the man's card a yd. stamp representing the 4^. which he deducts from the man's wages and his own contribution of 3d. The post-master general turns over the sums collected by the sale of insurance stamps to the central health insurance authority, — the insurance commissioners. The card is supposed to re- main in the hands of the insured person; but a working-man may leave his card with his employer. Employers may arrange with the com- mission for the quarterly stamping of the cards. At the end of each quarter, members of approved societies send their cards to their societies. Each society prepares a-quarterly return for the commission showing the number and value of the . contributions of the cards for which the society claims credit. The societies are required promptly to furnish members with new cards, and the stamped cards, surrendered to the societies, are finally forwarded to the commission. Benefits The benefits conferred on insured contributors are as follows: (i) "medical benefit" : medical treatment and attendance including drugs and appliances; (2) "sanatorium benefit": care and treatment when suffer- ing from tuberculosis or other diseases for which sanatorium care may be provided; (3) "sickness benefit" : the payment of a weekly cash allow- ance to insured persons when "rendered incapable of work by some specific disease or by bodily or mental disablement." The ordinary bene- fits payable in case of incapacity for work are 10s. ($2.43) a week for men and "js. 6d. ($1.83) a week for women.* Payments begin on the fourth day after such incapacity and may continue for a period of twenty-six weeks. (4) "Disablement benefit": a cash payment of 5.?. ($1.22) a week for men and women alike, which begins after the twenty-- * Editor's Note. The amending act of 1918 provides that persons becoming insured after July, 1918, shall receive these rates of benefit only after one hundred and four weeks of insurance. Before the expiration of .this period weekly benefits shall be 6j. ($1.46) for men and hs. ($1.22) for women. 3iS six weeks of sick benefit have expired and may continue up to the age of seventy years, when old age pensions are payable ; ( 5 ) "maternity benefit" : a cash payment of 30J. ($7.30) in case of the confinement of the wife of an insured person or of any woman who is herself an insured person. Medical and sanatorium benefit become available immediately, but full benefits are withheld until a specified number of payments have been made as follows : Sickness benefit is payable after contributors have been insured for twenty-six weeks and have paid twenty-six contributions. Maternity benefit, originally deferred for the same period of time, is, by the amending act of 1918, payable only to contributors who have been insured for forty-two weeks and have paid forty-two contributions. Disablement benefit is payable only after one hundred and four weeks of insurance and the payment of one hundred and four weekly contribu- tions. Medical and sanatorium benefits are administered by the insurance committees. Sickness, maternity and disablement benefits are admin- istered through so-called "approved societies." For such benefits Mr. Lloyd George said he believed the old friendly societies of Great Britain had "a great tradition behind them and an accumulation of experience which is very valuable when you come to deal with questions likCg malingering." However, not only friendly societies but trade unions, industrial insurance companies, and employers' provident funds may become "approved societies." Any surplus funds secured by a society through economical ad- ministration may be used for additional benefits, such as payment of sickness benefits before the fourth day of _ incapacity, medical at- tendance on the dependents of a society member, dental treatment or the payment of a superannuation allowance. Arrears The English act is liberal in the matter of arrears ; for no con- tributions are required during periods of reported incapacity for work, and benefits are gradually reduced instead of being totally withdrawn when arrears accumulate. The provisions of the original act dealing with arrears proved difficult of administration and amendments dealing with this subject were passed in 1913 and 1918. The original act provided that a person could cancel the arrears by paying, his own contributions and those of his employer for the missing weeks, but the amending act of 1913 made it necessary for him to pay only his own. Under the 1918 amendment the insurance commissioners may make regulations providing for the reduction, postponement or suspension of 319 benefits (except medical or sanatorium benefit which remain available) for persons who are in arrears. But in calculating arrears the act expressly provides that no account shall be taken of arrears accruing (a) during any period during which the insured person was incapable of work and of which notice was given within a prescribed time; or (b) in the case of an insured woman during two weeks before and four weeks after her confinement. Administration: Insurance Commissions and Committees Four different health insurance commissions were created for pur- poses of separate administration in England, Wales, Scotland and Ire- land; but a joint committee exists for the regulation of certain com- mon problems. Local administration is entrusted to local insurance committees which are organized in each county and county borough and to the health committees of county and borough councils. These committees may have from forty to eighty members and due provision is made in the act for the representation of the various inter- ests concerned. Three-fifths of the membership of a local committee are appointed in accordance with regulations made by the national in- surance commission and must "secure representation both of the in- "sured persons who are members of approved societies arid deposit con- tributors" ; one-fifth of the membership is appointed by county or county borough; two members represent the doctors and one to three members (depending on the size of the committee) must be doctors; and the remaining members are appointed by the national commissioners. Local insurance committees have the following duties: (i) ad- ministration of medical benefit for all insured persons ; (2) administra- tion of sanatorium benefit for all insured persons and their dependents ; (3) administration of sickness, disablement and maternity benefits for deposit contributors; (4) furnishing reports to the national insurance commissioners; (5) responsibility for dealing with the causes of "ex- cessive sickness" in any locality. Insurance is Carried by Approved Societies Insurance is carried through "approved societies," and any society may be "approved" by the insurance commissioners if it satisfies certain conditions, the most important of which are : ('i ) that it must not be a society carried on for profit; and (2) that its affairs must be "subject to the absolute control of its members." All contributions are paid into the treasury, which in turn credits to each society the contributions paid in respect to the members of that society. The utilization of the societies in the English scheme was believed to be a necessary expedient in view of their great strength. Mr. Lloyd George estimated that between six and seven million people had made 320 some kind of voluntary provision against siclcness chiefly through friendly societies before the introduction of the compulsory scheme. Ah account of the organization of friendly societies for the purposes of insurance and of the effects of the act upon the work of the societies will be given at a later point. Deposit Contributors Approved societies are entitled to reject any insured person who applies for membership, provided no applicant is rejected solely on the ground of age. The societies also have the right to expel members. Insured persons who are refused admission to any society and insured persons who refuse to join a society become "deposit contributors." Their contributions and their employers' contributions are credited to a special fund to be called the post-office fund; and their insurance is said to be carried by the post-office, although as a matter of fact they can hardly be said to be "insured" at all, since they receive in sickness, disablement or maternity benefit only the sums standing to their credit in the post-office fund. They do, however, receive medical benefits and sanatorium benefit. In 1914 there were under- half a million deposit -xoptributors: ■ ; ; ;,;:.;;^:_3S :,'&3»f;ss^ssta ~ Such are the main provisions of the act. The remaining poirtidu*, of this report will deal with health insurance'in Great Britain as it has actually worked out in practice. . '—:-f,.-^.M&'ll: HEALTH INSURANCE IN OPERATION The act went into operation and the collection of funds began July 15, igiXV. Benefits, however, were not to be granted immediately. In- "Tufed persons were to become eligible for sanatorium benefit immedi- ately, but the more important medical, maternity and sickness benefits wer^ not to be available until January 15, 1913, and disablement benefit, which only followed sickness benefit, could not begin until July 15, 1914. At the time when the war began, therefore, the act had been in force only two years and benefits had been in process of distribution for an even shorter period. It is important to keep this fact in mind for many of the criticisms directed against the act are due to con- ditioiis that inevitably arose in connection with the recent organization of so vast and complicated a piece of social machinery. Necessarily many details of organization were found to be unsatisfactory and S" changes were inevitable. The war has, of course, caused serious delays in the development of improved methods of administration and in the provision of additional benefits. That the great machine continued to work smoothly throughout the war was evidence of the stability of organization that had been achieved in so short a time; 321 British Doctors and the Health Insurance Act One of the first great problems that confronted the government after the passage of the act was the attitude of hostiHty adopted by the British Medical Association toward the provisions for medical benefit. During the two years from 1909 to 191 1, when a health insurance bill was known to be in preparation, the British Medical Association had been preparing for a vigorous defense of the interests of the medical profession. In June, 1911, the association had presented certain de- mands (called the "six points") that they wished incorporated in the bill. Certain of these demands, especially "free choice of doctor" and administration of medical benefit by insurance committees instead of by friendly societies were finally incorporated in the bill. Other dis- puted points (e. g., the question of remuneration) were left to be decided by the administrative authorities. In February, 1912, the British Medical Association again forwarded to the government certain peremptory demands, the most important of which related to the question of medical remuneration. The govern- ment had proposed an annual capitafion* fee of 4^. 6d. ($i.oq) ^f.g|^; j^octors and is. 6d. ($.36) for drugs and medicine. The association claimed a minimum capitation fee of 8s. 6d. ($2.06) for doctors, not including extras and medicine: In order to determine what was adequate remuneration, it was necessary to ascertain "the amount per head of the populaiiginigfeich was 7 ordinarily received by doctors in the course of their private practice.^' The books of the doctors in five important towns were exanjined, by^g^. committee of which Sir William Plender was chairman. The report, presented to Parliament July 11, 1912, showed that in the areas exam- ined the annual cost of visits and consultations, taking private and con- tract practice together, was approximately 4s. 5 J. ($1.07) per head of the population for consultations, for visits and for drugs. Various quali- fying factors were urged by the associated doctors, but the government remained firm in holding the demands of the association to be unreason- able and impracticable. On July 12, 1912, the British Medical Association broke oif all negotiations with the government and a "doctors' strike" was practically on. The strike was ultimately broken by a compromise.. On October 23, 1912, the government had announced some proposed grants-in-aid,^ additional sums which Parliament would provide for medical benefits. This made possible a capitation allowance of 8s. 6d. ($2.06) for drugs and medicine; and of this, 6s. 6c?. ($1.57) was assigned for the payment' of doctors on the panel, and the remainder for drugs, medicines and appliances. On November 4, negotiations with the government were again 21 322 opened by the British Medical Association, in part because of the gov- ernment's new offer and in part because the doctors saw that their strike was certain to fail. The government had threatened the appoint- ment of a sufficient number of salaried doctors in all districts where the panels were not filled, and these doctors were to be given permission to import a sufficient number of assistants for the local work and would, therefore, be given a threatened monopoly of local practice in areas where the doctors continued on strike. Doctors steadily joined the panels, and by January, 1913, there were nearly 14,000 doctors on the panels and there were very few, districts where panels could not be formed. Thus ended the attempt on the part of the British Medical Association to prevent the act from coming into force. The number of doctors on the panels has steadily increased, as will be seen from the following figures, showing the strength of the English panels as pub- lished in the official report on the administration of the insurance act for the year preceding the outbreak of the war (1913-14) : Strength of panels on January 15, 1913 13,996 Strength of panels on April 14, 1913 15,659 Strength of panels on October 13, 1913 15,870 Strength of panels on May 31, 1914 .' 16,059 The total increase in strength since the commencement of medical benefit- i s- tlru's offfP^ooo. The Panel System at Work Every insurance committee is required to prepare and to publish a list of doctors who have agreed to attend and treat insured persons. Every "duly qualified medical practitioner" has a right to be included in the panel ; and every insured person is given a free choice of doctors subject to the consent of the doctors selected. According to the statute, medical benefit is defined as "medical treatment and attendance, including the provision of proper and sufficient medicines and such medical and surgical appliances as may be prescribed by the insurance commission- ers." The statute provides, however, that "medical benefit shall not in- clude any right to medical treatment or attendance in respect of a confinement." The regulations of the insurance commissioners have put still further limitations upon the scope of medical benefit. Oper- ations requiring surgical skill are not required of panel practitioners, and X-ray diagnosis and pathological and bacteriological investigations are also excluded. Dentistry is left over as an additiona!l service to be provided in the future, and the treatment of the eyes and ears is held to be specialist service not required of panel practitioners. As a matter of fact, therefore, medical benefit has up to the present under the contracts with the doctors been held down to the treatment that 323 does not require the services of a specialist. This is in part the basis of the charge that the British system does not provide proper medical care for insured persons. Mr. Lloyd George, however, had promised the provision of the services of consultative experts and surgeons and it is reasonable to suppose that the medical service would have been developed to include these services but for the interruption of the war. Certain other criticisms of medical benefit under the British act should be examined. Two drawbacks to the panel system that were early revealed by the English act are (i) the uneven distribution of doctors in proportion to the population; and (2) the uneven distribution of work among such doctors as there are. An investigation made by the English Fabian Society in 1913-14 called attention to the fact that in pleasant suburban towns, it was not uncommon to find one doctor for every 500 persons, whereas in the industrial communities there might not be one doctor for every 3,000 people. Further the Fabian report says: Nor can we say that we have noticed much tendency to this geographical inequality of service 'being remedied by an inrush of doctors to the slums. There is, in fact, a distinct shortage of doctors, and this is, in itself, militating against the success of the Insurance Scheme. As regards the second point, it has been said that free choice of doctors by the insured population will in^^taE^^ffiad 301' uneven 'lists-, of patients among the panel practitioners. But the difficulty mighty of course, be remedied by limiting the number of insured persons allowed to each panel doctor. This change would probably be opposed by the doctors; but it appears to be necessary to safeguard the interests of the insured persons, who, according to Mr. Sidney Webb, have as yet shown no capacity for using their privilege of "free choice of doctor" intelligently. In the words of the Fabian report already referred to, the insured contributors have simply added their names to the list, however crowded, of the best known practitioners in their neighborhood. In town after town for which we have the figures, about one-fifth of the doctors on the panel are coping with half the total of insured persons, whilst four-fifths of the doctors divide among them, in comparatively small numbers, the other half. These points are also discussed by the English health insurance commissioners in their official report. They report that : As regards the. sufficiency of the number of panel doctors available for the country as a whole, there can be no possible doubt. . . The average number of insured persons per panel doctor is only about 750, a number for which re- sponsibility can, except under abnormal conditions, be accepted by a single doctor with the greatest ease. (Report for 1913-14, Cd. 7496, par. 469.) 324 As to the actual distribution of insured persons among the doctors, the commissioners say that : It is natural to expect that the forces of competition would result in the existence of lists above and below the average in size; and properly so, since it is right that competence and thoroughness- in attendance should be recognized and rewarded by a large practice and corresponding remuneration. The commissioners make the following further statement as to this situation: The early circumstances of medical benefit were, however, such as to dis- turb for the time being the operation of the competitive forces. In some dis- tricts doctors delayed coming on the panel at the outset, with the result that many selections were made before the panels were complete, and no opportunity subsequently arose for a change of doctor until the end of the year. Neverthe- less, the actual position as it existed prior ,to the first opportunity for change was far from unsatisfactory. Taking the figures of lOO Insurance Committees of a representative character, it appeared that at the end of 1913 over 50 per cent of the panel practitioners bad 500 or less insured persons on their lists, 70 per cent had 750 or less, 80 per cent had 1,000 or less, 90 per c«nt had 1,500 or less, while over 96 per cent had no more than 2,000. While the number of insured persons for whom a panel practitioner can properly accept responsibility will, of course, vary with his personal competence and the extent of his private practice, lists of the size above mentioned could not, save in exceptional circum- stances, be deemed excessive; and as regards the isolated instances in which doctors' lists greatly exceed these iigures, it- is generally the case that the prac- tice is shared with a partner or assistant. There are doubtless cases, however, in which a redistribution of panel patients could be effected with advantage to the patients themselves and the standard of the service afforded. Reforms in this respect are taking place, and will continue to do so, as the insured popula- tion become aware, and avail themselves of their opportunities of changing their doctors ; and the whole question is attracting the careful attention of Insurance Committees and the medical profession locally. (Report for 1913-14, Cd. 7496, par. 470.) It should not be overlooked that the British panel system represents a series of concessions to the doctors and has the advantage of enabling panel doctors to retain their private practice. Some of the difficulties that are encountered under the panel system are due to the attempts that have been made to preserve the conditions of private practice. The re- lations betvvreen the panel doctors and the insured patient remain very much like the old private relations between doctor and patient. It is inevitable therefore, as the health commissioners have noted in an official report, that as regards the standard and quality of treatment given this must inevitable vary under a system which admits to the panel all quali- fied practitioners without selection. There appears to have been singu- larly little complaint of the relations between panel doctors and their insured patients and, according to the last report issued before the war, "complaints are comparatively rare in most districts; while reports from all parts bear witness to an increasing spirit of mutual understanding." 32S There seems to have been little or no complaint as to the arrange- ments with the druggists or as to the quality of the drugs furnished. It is interesting that a letter from England dated April 5, 1913, published in the Journal of American Medical Association (Vol. 60, p. 1,268) calls attention to the decrease in the sale of nostrums and the simple remedies stored by pharmacists. The decrease was estimated at 20 per cent or more. In some working class centers the nature of' the pharmacy busi- ness has almost completely changed. In places where the amount of dispensing had been almost negligible, sixty or seventy prescriptions and even one hundred in some cases are dispensed daily. Finally, as to medical benefit, it should be said that a newly or- ganized service with 16,000 doctors giving service to millions of panel patients cannot work without causing some dissatisfaction to some of the individuals concerned. Moreover, no system can be devised that will serve 14,000,000 people to the entire and continued satisfaction of each. Some of the criticisms of the service given under the medical benefit regulations may well be attributed to this fact. Successes as well as failures of the system should be noted. The second annual report of the insurance commissioners contains the fol- lowing encouraging statement: The history of medical benefit since the publication of the last Report is a record of continuous improvement in the relations between the medical profes- sion and the authorities administering the Acts, and of steady progress and co- operation, on the part of all concerned in the work of perfecting the administra- tive fabric, not only by means of the elimination of defects revealed by experi- ence or unavoidably due to the circumstances attending the inception of the benefit, but also by means of the extension and adaptation of the machinery so as to secure a more complete enforcement of the rights and duties already established. (Report for 1913-14, Cd. 7496, p. 156.) Significant, too, is the further statement by the commissioners that signs are not wanting that definite tendencies are in operation, originating with the medical profession themselves and fostered by the responsible authorities, to raise th« standard of the whole of the industrial practice of the country and to enhance the value of the insured service. Further evidence of the steady progress that has been made toward improving the administration of medical benefit has come more recently from the British Medical Association. This testimony of June, 1917, is significant in view of the recalcitrant attitude maintained by the as- sociation toward the act in its earlier stages. In an interim report on the "Future of the Insurance Acts," which was based on replies to a questionnaire widely distributed among the branches and divisions of the British Medical Association and the local medical and panel committees, the insurance acts committee of the association makes the following state- ment :^ 'British Medical Journal, June 23, 1917, Supplement, p. 687. 326 On a sutject which five years ago was the most highly controversial that had ever been before the medical profession, . . . it is found (i) that many matters which at the beginning of the controversy gave rise to most apprehension have assumed a position of quite minor importance; (ii) that the general system by which the state provides medical advice and treatment under the insurance act is in the main approved, and ithat criticism has a tendency to concentrate on a comparatively few points wlhich . . . are, after all, matters of detail which ought to be capable of adjustment; and (iii) that there is a large body of opin- ion in favor of the extension of the health insurance system both to kinds of treatment not at present provided for and classes of persons at present excluded therefrom. It is of further significance that the results of the questionnaire were said to reveal a remarkable unanimity of opinion among the medical pro- fession supporting this changed point of view toward the insurance sys- tem. The present attitude of the British Medical Association seems to be one of approval of the insurance system and of fear that the government in pressing forward its plans for school medical services, maternity centers and tuberculosis dispensaries "has resolved to allow the National Insurance scheme to die from inanition, or by gradual under- mining in favour of a system of whole time state medical officials."" Approved Societies and the Insurance Act Membership. After the passing of the insurance act, the old friendly societies and trade unions organized state sections of their organizations which became "approved societies" under the law. New approved so- cieties were formed very hastily, and many of these were for special groups of workers who had in the past failed to join such organizations. But vast numbers of workers who- had heretofore been uninsured were drawn into the new organizations formed by the commercial insurance companies. The Prudential, for example, quickly formed six "Pruden- tial approved societies" which enrolled more than three million members. Similarly the "National Amalgamated Approved Society" (formed by two other commercial companies) enrolled over a million and a half members, and smaller companies appear to have formed similar "state sections" as approved societies. This activity of the commercial com- panies was undoubtedly not foreseen by those responsible for the act aiid appears to be undesirable since they are not really democratically con- trolled as the act intended the approved societies to be. The following table shows for the United Kingdom the number of members (men and women) of the different types of approved so- cieties as pubhshed in the report for 1913-14, the last report issued be- fore the outbreak of the war, when conditions were still normal. ° See letter from the insurance acts committee of the British Medical Asso- ciation to National Health Insurance Joint Committee, British Medical Journal, Supplement, 1917, p. 101. 327 Membership of Approved Societies, United Kingdom, 1913-1914 Type pf society Men Women Total Friendly societies with branches 2,468,119 2,456,747 1,233,570 3,115,270 87,238 665,358 931,719 233,010 2,173,291 23,460 3,133,477 3,388,466 Trade unions 1,466,580 Industrial assurance companies and col- lecting societies 5,288,561 110,698 Total . . 9,360,944 4,026,838 13,387,782 472,272 Total insured nersons 13,860,054 Over-insurance. The national insurance act carries a provision against double insurance. No person can become an insured person un- der the act, i. e., with contributions from employer and from the state added to his own, in more than one society ; but he may, of course, be a member of several societies independently of the act. It appears to be not uncommon for a man to carry insurance through the "state side" of one society and additional insurance through the private or voluntary side of that or another society. In the old friendly societies the great majority of the members (in general about 90 per cent or more) con- tinued their full contribution and were insured both on the "state side" and the "voluntary side." As a result, insurance for a sum in excess of the normal wage of the person insured is now by no means uncom- mon. An insured person may therefore draw a larger income when he is "on sick benefit" than he earns when at work. Should over-insurance be allowed? In considering this question it must not be forgotten that expenses are greater in time of illness, that special and more expensive food is required and that more care is needed. Nevertheless, this argument applies only to cases of genuine illness, and the fact remains that a temptation to draw sick benefif un- necessarily may exist in cases where more money can be drawn in this way than by remaining in work. Administration of Sickness Benefit The greatest problem that arose in connection with the administra- tion of sickness benefit was the allegation that excessive sickness claims were being made. Early in 1913 it appeared that claims made upon the approved societies for sickness benefits were in excess of the estimates made by the government actuaries. In the summer of 1913, therefore, a departmental committee of sickness benefit claims was ap- pointed in order to determine whether these alleged excessive claims were due to defects in the machinery provided for establishing claims 328 upon the sickness fund, or to "malingering" among insured persons, or to errors in the actuarial estimates. The Machinery for Establishing Sick Benefit Claims. In con- sidering the possibility of defective administrative machinery as an explanation of excessive sickness claims, it should be pointed out that although the approved societies are obliged to pay claims for sick- ness benefit as prescribed in the health insurance act, different societies may adopt different methods for making or proving such claims. Op- portunities for differences in policy are especially likely to arise as re- gards such points as the definition of the term "inability to work," the questioning of doctors' certificates of incapacity, the system of visiting the sick in their homes during the period when benefits are being paid, or the discipline imposed on members receiving benefits. '' The meaning of the term "incapacity for work" is all important in the allocation of benefits. Sickness benefit in the statute is defined as "periodical payments whilst rendered incapable of work by some specific disease or by bodily or mental disablement." This has not been inter- preted literally as complete incapacity but merely as incapacity rendering members "unable to following their ordinary employment." The prac- tice of the societies is to accept medical certificates of incapacity given by panel doctors as the proof of a claim for sickness benefit. A difficult question of policy is met at this point. Shall the offi- cials of an approved society question doctors' certificates? The official report on the administration of health insurance, 1913-14, called attention to the fact that Parliament had virtually placed the safety of the societies at the mercy of the panel doctors, since the ex- penditure on sickness benefit was dependent on sound certification, and that the doctors had not shown themselves worthy in all cases of the con- fidence reposed in them. Similarly the Report of the Departmental Committee on Sickness Benefit Claims noted that the doctors under the act adopted a new attitude toward the friendly society. While formerly doctors were ready to look after the funds, they are not now prepared to consider the society at all. . . . With regard to those doctors who are now engaged in this kind of work for the first time, there is reason to believe that with some exceptions they do not correctly apprehend the nature of their task, the value ,to be placed on their certificates, the relation in which they should stand to the society or their responsibility to the working of the whole machine. On the other hand the friendly societies appear to have changed their earlier policy of cooperation with the doctors in passing on sick- ness claims. In the old days the officials had followed the practice of notifying doctors of any suspicious behavior on the part of members 'These questions of policy were dealt with at length in the Report of the Departmental Committee on Sickness Benefit Claims (Cd. 8396). 329 who had been certified as incapable of work; and there was a constant check on doctors' reports, and "the intimate knowledge which they had of their fellow members and their close relations with the doctor en- abled them to exercise a very real and effective check on the certificates received." Under the national insurance act the problem of the societies had grown more difficult, in part because of the increase in the size of their organizations and in part because the new membership was drawn from those large sections of the population who were new to the prin- ciple of sickness insurance. The Panel Doctors and the Societies. Serious difficulty appears to have been caused by the fact that the large body of certifying doctors had had no experience with friendly society practice. Under the old system, when the medical man was an officer of the society dealing with patients whose characteristics both he and the officials knew more or less intimately, there was less scope for conflicts of opinion as to cer- tification than under the new system, when patient, doctor and official were comparatively ignorant of and out of close relationship with each other. I ;j : I ■i\ i For the new difficulties of certification, the approved societies were, however, in large part responsible ; the new societies had not adopted and the old societies had often relaxed the policy of questioning the certifi- cates and without the helpful scrutiny of the officials of the society, the doctor was powerless to certificate and discharge satisfactorily. This may be illustrated by one of the cases brought to the attention of the departmental committee on sickness benefit claims : In this case an insured person who was earning only 22s. a week but was insured for Ms., with a previous record of obtaining ten weeks' benefit a year, claimed sickness benefit after preliminary inquiry ito satisfy himself that he was in benefit to the full amount. In this case the local secretary and the sick steward were both satisfied that the man, who beguiled the tedium of his leisure by attend- ing ito his pigs, "did not seem ill in the least," yet they professed themselves obliged to pay benefit because he produced a certificate from a doctor, who according to belief entertained by the local secretary, "gives a certificate to any- one who asks him for one." Apparently, no attempt was made to comniunicate to the doctor the grounds on which the society's suspicions were based. In such cases it is apparent that the doctor and the society are alike at fault. It is clear also that the difficulties are largely due to the fact that the system is new and that the administrative machinery is not yet satisfactorily organized. All that is necessary is that the officials of ap- proved societies revive the old practice of utilizing their knowledge of the habits and the behavior of the insured person as evidence which must be taken into consideration along with the medical certificate, if necessary after consultation with the doctor, before a decision is arrived at on the question of paying the claims. 330 Excessive Sickness Claims and the Problem of Fraud. Among the witnesses, medical and other, who testified before the departmental com- mittee on sickness benefit claims, there was a unanimous agreement that there was no "appreciable amount of fraud" in claiming sick benefit; some testimony was given, however, both by doctors and by representa- tives of approved societies showing that without any deliberate fraud there was some evidence of difficulty "in getting an insured person who had once declared on the funds to declare off," — a kind of unwilling- ness on the part of insured persons "to bring the period of incapacity to an end." The desire to claim sickness benefit during convalescence may be a reasonable one, but the committee found it necessary to emphasize the fact that under the terms of the national insurance act, sickness benefit was not properly payable during convalescence, nor was it payable on the ground that a period of rest would be "good for" the insured per- son. Under the act, sick benefit can be paid only to meet loss of wages because of incapacity for work owing to sickness or mental or bodily disablement. Some testimony was offered to show that persons were less willing to declare off the sick funds when they had no work to go to. This tendency to use or continue sick benefit as a kind of unemployed benefit had been fostered in the old friendly society days, and it was said that "successive generations of society officers have winked at the practice." Excessive Sickness Claims and the Novelty of Insurance. Exces- sive claims were also said to be due to the novelty of insurance. For large sections of the adult male population and for practically all gain- fully employed women, the right to draw "sick pay" in lieu of wages when unable to work was an entirely new experience. In the beginning the situation was not clearly understood, and most of the insured per- sons knew only that they were making weekly payments of small amounts in order that they might draw out weekly benefits of large amounts. There was also, said the committee report, "a certain amount of evidence of an intention to get the most out of the act, pointing rather to an overkeenness of business instinct than any attempt at dishonest prac- tices." On the whole, therefore, in so far as there were unnecessary claims for sick benefits, the committee laid the blame chiefly upon faulty ad- ministration. "The claims," it is said, "tend to excess in those cases in which the inexperience of the administrator, or his over-experience in bad methods provides an inefficient machine" ; and, further, it is noted that "a laxity on the part of the society leads inevitably to an excess of claims on the part of the insured member." Obviously and fortunately, such administrative faults are remedial, and the most recent' official report on the administration of the health insurance notes an improvement dur- ing the period 1914 to 1917. 331 During this period the claims for sickness benefit decreased and while special causes arising out of the war are held to be largely respon- sible for this decrease nevertheless some part of it may doubtless be at- tributed to improvements in administration which should be permanent. The statement of the insurance commissioners on this point is as follows : While special causes have produced much of the improvement in the claims, it cannot bt doubted that administration has also exercised an important in- fluence. There is good reason to think that some part of the high cost of sick- ness among women in 1913 and 1914 was not normal, hut was due to a certain extent to the application of inexperienced supervision to the claims of a class to whom any sickness insurance was in the nature of a novelty. Careful manage- ment should do much to prevent a recurrence of the high rate of claims which prevailed during these years. Excessive Sickness Claims and the Actuarial Estimates. Excessive sickness claims might also, of course, be attributed to errors in the actuarial estimates. The act provides for a flat rate of contribution, and the actuarial estimates were based on a general average expectation of sickness for the whole insured population. The actuaries cound not, in advance, make proper allowance for the fact that the population was not to be insured as a whole but was to be divided into separate societies in which there would be cases of the segregation of persons who were "bad risks" from the insurance standpoint. As a matter of fact, ap- proved societies differ greatly not only in the type of organization adopted but in the character of their membership. The large societies contain fairly representative groups of the whole insured population. Some societies, however, are exclusively made up of women or of men. In other societies the membership is selected on some special basis such as a common occupation, residence in a particular locality, church mem- bership or even the practice of total abstinence. Persons engaged in trades that are hazardous and likely to produce sickness will, if asso- ciated in a single society, bring a high sickness rate to that society. It is clear, therefore, that when a society exceeds the actuaries' estimate of the expected sickness rate, this may be due to the fact that th membership contains "an abnormal proportion of lives of a particu- lar type exposed to a sickness risk in excess of the general sickness risk of the whole population." On the whole, it appeared that as regards men and even as regards women, the actuarial provision had been adequate but the sickness claims of married women had been in excess of the Actuarial provision. But the experience of different societies inevitably differed and differed widely. In some, the claims greatly exceeded the actuarial estimates, and in others they were well within the actuarial allowances. ° Great Britain, Report on Administration of National Health Insurance, 1914-17, (Cd. 8890), p. 12. 33^ These difficulties were inevitable under the democratic British sys- tem, which recognized the great insurance organizations that had been built up by the people and gave to the insured free choice of carrier. Did Mr. Lloyd George commit a grave error in utilizing approved so- cieties as insurance carriers? Can administration by independent ap- proved societies be made sound and efficient? Already steps have been taken to remedy the difficulties caused by the segregation of risks, but the principle is apparently not to be changed. A departmental com- mittee on approved society finance and administration was appointed in January, 1916," and this committee emphasized the fact that a flat rate of contribution under conditions permitting the segregation of insured persons "into societies of distinctive occupational hazard" had certain defects. The committee recommended, however, that these defects should be remedied not by the abolition of approved society adminis- tration but by additional exchequer grants toward a special risks fund. The national insurance amendment act of 1918 has met the situation by the creation, with the aid of special Parliamentary grants, of a central fund and a women's equalization fund to protect the societies in which an abnormal rate of sickness prevails. Effect of the Insurance Act on Friendly Societies. Will the attempt to administer the insurance act injure the friendly societies instead of strengthening them is another question that may be raised in connection with the approved society problem. The testimony of working class leaders seems to be that there is grave danger that the act may destroy what was most valuable in the old friendly societies. Testimony before the departmental committee on sickness benefit claims was to the eflFect that "as the various organizations grew, the intimate personal coopera- tion on which they were based tended to become weaker." It was said that the sentiment on which friendly societies were built was a "dying spirit." "There has been a tendency for what was originally the ex- pression of a bond of good fellowship and a desire to help one another to pass to some extent to a matter of mere business. The active mem- bers have been fewer in number ; the social side has not been so prom- inent as formerly." A working class leader who was a member of the committee on sickness benefit claims said: The administration of a compulsory state insurance is a burden, and not a help, to friendly societies and trade unions. The energies of these democratic institutions are strained to the breaking-point and the time of many of their ablest officials is spent on matters foreign to their true aims (Cd. 7687, p. .85). It is apparently difficult to find a way of preserving local pride and interest with the centralized control and supervision necessary to effi- " Interim Report (Cd. 8251), May 1916; Further Report (Cd. 8396), October 1916; Final Report (Cd, 8451), December 1916. 333 cient management. Strengthening the central government is likely to destroy local enthusiasms and to produce local ignorance and indiffer- ence, "the decay of local spirit, the carelessness of the individual as regards the prosperity of his society, the dehumanizing of the whole machine." The Breakdown of Democratic Control. In the opinion or sonie working class representatives the theory of democratic control upon which the administration of the act by large numbers of independent approved societies was based has completely broken down. This plan was originally adopted in order to meet the wishes of the working classes, but their opinion seems to be that it has not been wholly suc- cessful. One of their representatives said, for example, in testifying- before a Parliamentary committee : ^'' In theory, this plan of administration was excellent. It was hoped by this method to secure democratic self-government by insured persons of insured per- sons. The funds were to be protected by identity of interest and the extension of the old Friendly Society spirit into State Insurance. To secure these ad- vantages a contributory scheme was reluctantly accepted by a majority of the working class representatives. For these advantages economy, simplicity, uni- formity of management, and the pooling of risks over the whole community were sacrificed. In practice, however, the ideals of democratic government and ab- solute control by members of their own affairs have frequently been non-existent. In the large industrial insurance companies which hastily secured the membership of more than a third of all insured persons, the members cannot be said to have any effective control over the organi- zation; and in the old friendly societies the old forms of local self-gov- ernment seem to have been giving place more and more to centralized systems of control. Radical changes in administration may yet prove to be necessary. Working class leaders fear on the one hand the disor- ganizing effects of the act upon the working-men's societies and resent on the other hand the undemocratic methods of the commercial insur- ance companies. The Administrdtion of Sanatorium Benefit Sanatorium benefit is largely a tuberculosis benefit, and on the administrative side, it is a question of cooperation with the local author- ities in providing the necessary dispensaries and sanatoria. A special departmental committee on tuberculosis was appointed in February, 1912, and the two reports issued (April 1912, Cd. 6164, and March I913, Cd. 6641) recommended the adoption of comprehensive schemes for providing adequate care for the whole population through "Great Britain, Report of the Departmental Committee on Sickness Benefit Claims (Cd. 7687), p. 83. 334 the cooperation of insurance committees with the public health authorr ities and local government agencies such as the county councils. The government, therefore, undertook the making of grants-in-aid not to the insurance committees but to the local authorities. That is, in place of a scheme for insured persons and their dependents organized by insur- ance committees and financed out of their income supplemented by con- tributions from the exchequer &nd the rates, the plan came to be, in the words of the annual report for 1913-14, "comprehensive schemes for whole areas organized by the local authority and financed partly out of rates and partly by the aid of contributions from insurance committees and the exchequer." Before the outbreak of the war more than a hundred councils had submitted to the local government board, schemes looking toward com- prehensive treatment, including the provision of dispensaries, sanatoria and hospitals, both for insured and uninsured members of the population. In spite of the delays and interruptions caused by the war, the tuber- culosis schemes have been carried forward. The number of tuberculosis dispensaries had increased, for example, from 255 in June, 1914, to 370 by August, 1917;, the number of beds in approved residential institutions had increased from 9,200 in June, 1914 to 11,700 in August, 1917. Criticisms of the inadequacy of provision for tuberculosis appear to be very general in spite of the progress that has been made. Indeed, in view of the magnitude of the problem, it could not be expected to be otherwise. The insurance acts committee of the British Medical Asso- ciation reported general agreement to the effect that the public funds provided are not sufficient to enable proper provision to be made for all tubercular persons needing help to obtain suitable treatment. It is probable that such funds as are available are not always used wisely. . . - The administration of some insurance committees and of some public health authorities in this matter is far less efficient than that of others, and the fact that these two bodies have dual and overlapping powers is inconvenient and undesirable. Further testimony as to the unsatisfactory character of the provision for tuberculosis may be found in the report of a committee (February 1917) appointed by the faculty of insurance to consider the national! insurance act. This committee cordially endorsed the results of the medi- cal, sickness and maternity benefit but reported as to the sanatorium, benefit that the act had been disappointing: That the tuberculosis scheme cannot be regarded as a success; and that, in all probability much better results would be obtained were the existing system of overlapping control brought to an end and the whole responsibility vested in one public health authority. 335 The Administration of Maternity Benefit ■ This benefit has been perhaps the most popular feature of the in- surance act and the one that has presented the fewest problems from the administrative standpoint. The act originally provided for the pay- ment of a lump sum of 30?. ($7.30) in case of the confinement of the wife of an insured person or a woman who was herself an insured per- son whether she was married or not. An insured woman was under the original act also entitled to sickness benefit or disablement benefit after her confinement. A further provision of the act was that where the husband was an insured person and the maternity benefit was payable in respect of his insurance, the maternity benefit was "the husband's bene- fit." The act did indeed provide for the punishment of the husband if he failed to. make provision for his wife's care, but this was like locking the stable after the horse had been stolen. An amending act in 19 13 made the maternity benefit in every case the "mother's benefit" payable only to the woman herself or to the husband on her order. The provision in the original act giving a woman who was herself an insured person the right to sickness benefit during confinement in addition to the husband's maternity benefit when her husband was also an insured person did not work very smoothly. In the actuarial scheme of the act, an incapacity of four weeks was allowed for, which with the sick benefit for ■yvomen of ys. 6d. ($1.83) a week would have meant a payment of 30.J. ($7.30) as sick benefit in addition to the 30J. maternity benefit. Many societies followed the policy of giving an additional 30J. as a lump sum in such cases irrespective of the period during which the insured woman was incapacitated for work by reason of her confine- ment, whereas the act obviously intended this special form of sickness benefit for insured married women to be subject to the same conditions as are attached to sickness benefit generally, viz., a weekly sum payable only so long as the society is satisfied that the woman is actually incapable of work. Since the policies of the different societies varied so much with re- gard to the payment of the additional 30.?., the amending act of 1913 provided in place of sick benefit for insured married women an addi- tional maternity benefit of 30J. payable without any proof of "incapacity for work" being required. On this basis maternity benefit is being dis- tributed at the rate of approximately a million and a quarter pounds an- nually, 30^. ($7.30) going to every mother who has an insured husband and 6o.r. to every mother who is herself an insured woman and the wife of an insured man. Until the passage of the amending act of 1918 maternity betiefit was payable after an insured person had been twenty-six weeks in insurance and had paid twenty-six contributions (in the case of voluntary con- tributors fifty-two weeks and fifty-two contributions) . The 1918 amend- 336 ments made maternity benefit payable only after a period of forty-two weeks' membership and forty-two contributions (uniform for compul- sory and voluntary insured persons). The extension of the period of twenty-six weeks was found to be necessary in order to prevent " 'con- structive' entrance to insurance for the purpose of drawing maternity benefit." It was believed that the addition of sixteen weeks and sixteen contributions would be "an effective deterrent to a growing tendency to engage in work for a few days in order to secure maternity benefit." ^^ The maternity benefit has been regarded with almost universal ap- proval. Criticisms made by such organizations as the Women's Coopera- tive Guild and the Fabian Society ^- cover two points : 1. That the scope of the act is not wide enough and that there are still too many uninsured mothers. 2. That maternity benefit does not insure adequate attendance at childbirth, with adequate provision for infant care. The proposal has therefore been made both by Mr. Sidney Webb's Fabian Committee of Inquiry and by the Women's Cooperative Guild that the care of both pregnancy and maternity should be taken out of the insurance scheme altogether and given to the local public health authorities assisted by grants-in-aid from the government. The strain on the funds of societies which have women members would be removed by this change, and proper care would be given to every mother and child regardless of whethaf .^r liot either or both patients happen to be insured persons in good standing. This would practically make mater- nity and infant care a non-contributory form of state aid, and it is prob- able that such provision will be made under the proposed ministry of health. Attention should, however, be called to the opposition of the British Medical Association to this plan. The association is not in favor of withdrawing any benefits from the insurance act and substituting a system of universal provision under whole time state medical offi- cials.^^ Whatever changes the future may bring as to the extension of maternity benefit, such assistance as the insurance act now provides has been greatly appreciated by those who know conditions of life among working women, e. g.. Miss Margaret Llewelyn Davies, of the Women's Cooperative Guild, wrote recently:^* " See comments in the Supplement to the British Medical Journal, November 17, 1917, p. 708. ^^ See The New Statesman, Special Supplement on the Working of the In- surance Act, March 14, 1914, p. 24. '" See extract from letter by insurance acts committee of the British Medical Association to National Health Insurance Joint Committee. British Medical Journal, Supplement, 1917, p. 101. "Women and the Labour Party (edited by Marion Phillips), pp. 32, 33. 337 The maternity and pregnancy sickness benefits of the insurance acts are important steps in the direction of the mother's economic independence. With the advent of a ministry of health, in connection with which we hope to see a strong maternity and infancy department, largely staffed by women, an oppor- tunity arises for deciding the relation which public health and insurance should have in provision for maternity. . . . But maternity benefit has been an epoch- making reform, not only because it is the recognition by the state of the claims of motherhood, but because it has been made the mother's own property. 'CONCLUSIONS How far has the British health insurance experiment succeeded? Much can be said in criticism of various points of administration, and attention is too often concentrated on these controversial points. Mr. Sidney Webb, whose criticisms of the act have been perhaps too fre- quently quoted in this country, said that he had dealt largely with what he "believed to be t'e defects of the scheme in order that alterations and amendments might be brought under discussion. He was emphatic, how- ever, as to the value of the act as a whole and said in the opening para- graph of his well-known Fabian report: We cannot pretend to measure the advantage, to individuals or to the com- munity, of the really gigantic provision thus made for the periods of incapacity — ^ however far short of completeness or perfection the provision may be deemed. However faulty in plan we may consider the scheme to be, and however* defective in operation, ■ the allocation of. so large a sum as twenty millions [pounds] per annum must necessarily relieve a vast amount of personal suffering and mitigate the dire poverty of innumerable families in their hour of need. Moreover, though it is as yet too early to enable any statistical evidence to be obtained, it is scarcely possible to doubt that the results in connection with public health and infant mortality. must be advantageous. The following table summarizes the expenditure of the approved societies on sickness, maternity and disablement benefits in the United Kingdom from the beginning down to the year 1917. Expenditure on Cash Benefits, United Kingdom, igis-igi6 Year Sickness benefit Maternity benefit Disablement benefit Total 1913 1914 1915 1916 Total $31,895,106 35,036,156 30,674,981 28,187,429 $6,158,195 7,154,246 6,417,757 6,132,464 $935,147 4,095,454 5,576,382 1125,793,672 125,862,662 $10,606,983 $38,053,301 43,125,549 41,188,192 39,896,275 $162,263,317 The expenditure on sickness, maternity and disablement benefits alone during the first four years in which the act was in operation reached a total of more than $162,000,000 and this entire sum repre- 338 sents money paid directly into the homes of the workers to relieve and prevent the destitution that would otherwise be caused by illness. It is these benefits which have been in part responsible for the decline of poor relief in various parts of England. It has been said for example of the Liverpool dock hands that: In 50 per cent of the cases where sickness benefit has been granted, the home would have been broken up, the furniture sold, and the family engulfed by the workhouse if it were not for the sickness benefit granted by the Act. Gen- erally also, it is said that there is less of what the doctors call "walking sickness" since the Insurance Act has come into force, and the man who should be in bed instead of struggling with pain and weakness at his daily task is able to give the doctor a fair chance of making a good job of his case. The act has been severely criticized by Dr. Brend in his book "Health and the State" on the ground that it is a public health measure, that its main object was to improve the hea. h of the working part of the community and that it must be judged solely by its effect on public health. Aside from the fact that it is much too soon to measure the effect of the act on public health, these criticisms ignore the purpose of the act in preventing destitution. The national health insurance act is a public health measure obviously, but it is also, and perhaps primarily, an act to prevent destitution and pauperism. Mr. Lloyd George, in introducing the bill, said that it was a direct consequence of the old age pensions act, which had revealed a mass of poverty "too proud to wear the badge of pauperism." As the old age pensions act had been a bill to prevent pauperism among the aged, so the national health insurance act was de- signed to prevent pauperism of the sick and to remove the working-man and his family from the poor law during periods of illness. Dr. Brend concludes his chapter on health insurance by saying that : ... In taking a broad view the advantages of the act must not be minimized. The weekly payments of sickness benefit have undoubtedly helped many poor people through a period of distress. Maternity benefit has been a substantial benefit to mothers and disablement benefit has constituted a small pension for incapacitated persons. Nevertheless these benefits are held to be negligible by Dr. Brend because he believes that the effect of the act on the public health during the few years in which it has been in operation "has probably been al- most nil." The medical service is said to be no better than "that which preceded it," and the fact that this service is available now to several million people who had not enjoyed the advantage of friendly society medical service in the past is considered of no importance. The medical service under the panel system has its defects, and some of them have been referred to in this report ; but the health commissioners in their sec- 339 ond annual report stated the case very fairly as to medical benefit with all its drawbacks, when they said: At the Igwest estimate of the position, an enormous number of men and women are now receiving treatment for their ailments who previously were accustomed to go without; while on the other hand, insured persons have been enjoying at the hands of the more conscientious and competent doctors, a service of the standard of that accorded to remunerative patients of the well-to-do classes. Further, the social value of the act should not be overlooked. On this point we can do no better than quote Miss Mary Macarthur, presi- dent of the largest of the women's trade unions, who said in an official report : There can be no two opinions as to the great social value of the Act, in revealing the condition of the mass of working women, and the effect which their low wages have upon their health — -questions which up to now have been almost totally neglected. As has been shown, even doctors in poor practices have been amazed ait the amount of unexpected and unrelieved suffering that has teen brought to light. The Act has shown the country what poverty means. It has shown that people who are underfed, badly housed, and overworked are seldom in a state of physical efficiency; and has expressed in terms of pounds, shillings and pence the truth, that where an industry pays sitarvation wages, it does, in literal sober fact, levy a tax upon a community (Cd. 7687, p. 86). In conclusion, emphasis must again be laid upon the fact that the health insurance act in Great Britain had been in operation only two years and that the most important benefits had been administered for only a year and a half, when the war broke out. Inevitably there were many imperfections to remedy and before the necessary changes could be made, the great war began to absorb the resources, the time and the thought that would otherwise have gone into the business of perfecting the schemes of social reform that had been launched by Mr. Asquith's government. The effect of the war in retarding the development of the health insurance organization has already been referred to. In the budget of 1914, the supplementary estimates contained the following proposed health insurance grants from the national exchequer : (i) Sickness benefit (Women) (grant-in-aid) $2,430,000 (ii) Medical referee consultants, etc 243,000 (iii) Supplementary medical services 243,000 (iv) Nursing grants (grant-in-aid) 486,000 (v) Sanatorium benefit (grant-in-aid) 486,000 Owing to the outbreak of the war it was' considered inexpedient to proceed with any of these new proposals. It soon became apparent that all the work of the depleted staffs of the national health insurance com- mission as well as the work of the seriously depleted staffs of the local 340 insurance committees and approved societies would have to be devoted entirely to the continuance of routine work under the act. On the whole it is clear that the war has had a definite effect in retarding the progress of health insurance, and it is only fair that due allowance should be made for the setbacks caused by the war in assessing the results of this great British experiment. APPENDIX C SICKNESS INSURANCE IN GERMANY Henry J. Harris, Ph. D. Chief, Division of Documents, Library of Congress Obligatory insurance against sickness on a national scale began with the law of 1883, but like most social institutions there is prior to this date, a long history of efifort to provide aid against distress due to this cause. The earliest forms of sickness relief were found in the case of seamen, miners and domestic servants; the first two of these, it will be noted are industries which closely resemble modern large scale production and in which, therefore, the employees had a special claim upon the employer because the place where work was carried on and the conditions under which work was done were determined almost solely by the employer. At the beginning of the nineteenth century many special forms of providing relief in case of sickness and accident were in use; the guilds had their sickness and burial funds, the miners had even more elaborate arrangements while seamen had special claims against their employers in case of disability. The movement took a more definite form in the industrial code of Prussia of 1845, which authorized the local governments to make membership in such a relief organization compulsory; in 1849 this law was amended so as to permit the local governments (communes, towns, etc.) to compel employers to create relief funds and to reqitire the employers to bear a portion of the expense. By this time mutual aid funds, somewhat similar to the British friendly societies, began to develope and the law of 1869 stimu- lated this movement. The imperial law of 1876 encouraged the move- ment further, so that by 1880 there was a wide variety of sick relief organizations in operation and the plan of such insurance was familiar to most of the industrial population. It is not easy to determine exactly the motives of the German government in proposing a universal compulsory system of sickness in- surance at this time. Bismarck stated that the reason was to secure a means of opposing the socialist movement; others stated that it was a plan to raise wages on a national scale while others claimed that it was a consistent part of the state policy of caring for the inhabitants in dis- tress. • The proposal was introduced into the Reichstag* in 1882 and be- came a law on June 15, 1883. Since that date numerous improvements and extensions in the law have been made, the most important of which (341) 342 are the laws of 1892, 1903 and 191 1. The first two of these extended the occupations and industries covered by the insurance, increased the benefits, allowed more freedom in movement from one fund to another and provided for a secret ballot among the insured persons in selecting their representatives. While this movement was going on in the field of sickness insurance, similar progress was made in providing compulsory insurance against industrial accident and against old age and invalidity. These systems were closely connected with the sickness system; in case of industrial accident the sickness insurance cared for the injured person for the first thirteen weeks, after which the accident organizations assumed the care ; in case an insured person contracted a disease of long duration, the sick- ness organizations provided the care for the first thirteen weeks (after 1903, the first twenty-six weeks) after which the invalidity institutes took charge. Beginning with 1900 many plans were put forward for the con- solidation of the three systems and the simplification of the numerous laws on the three subjects. The proposal for the amalgamation of the three forms of insurance into one system of carriers for all three was finally rejected, but in 191 1 a general codification of all the laws on the three forms of insurance was adopted. This code, the imperial insur- ance code {Reichs-V ersicherungsordnung) , became a law on July, 191 1 and the section of it relating to sickness insurance came into force on January i, 19 14. The scope and operations of the sickness insurance system up to the year 1909 have been described at some length' in the Twenty-fourth Annual Report of the United States Commissioner of Labor.^ This re- port, however, was written two years before the enactment of the code of 191 1 and only mentions the draft of the provisions of that act. In the following pages the description of the sickness insurance system is based on the 191 1 law. The outbreak of the war in 1914, however, prevented the publication of any data relating to operations since January, 1914 — in fact most of the information available stops with the year 1912. The statistics of operations here given in this summary statement therefore relate to the period prior to the time the system here described came into operation. The benefits provided, however, are practically unchanged in the new law and most of the changes relate to administration, the ad- dition of certain groups of occupations (such as agricultural labor) and a closer cooperation with the accident and invalidity insurance. PERSONS INCLUDED The persons included in the compulsory insurance under the law of 191 1 are in general those employed for compensation; persons employed 'Workmen's Insurance and 'Compensation Systems in Europe, 24th, Annual Report' of the United States Commissioner of LcHbor, Washington, 1911, 2 vols. 343 in supervisory and clerical positions are only included if their annual compensation is less than 2,500 marks ($595). The law specifies work- men, helpers, journeymen, ai^prentices, servants, managers of establish- ments, clerks, etc., in commercial establishments and in pharmacies, stage and orchestra employees, teachers, persons engaged in homeworking in- dustries, persons employed in navigation not covered by other laws, per- sons employed in agricultural work which is subsidiary to an industrial establishment and to apprentices. Employees of establishments of or in the service of a government (national, state, local) are exempt from the insurance only if they are entitled to benefits approximately equal to those of the law. An employed person automatically comes under the compulsory in- surance provisions when his name is placed on the pay roll of an estab- lishment. The funds may not make admission dependent on a medical examination or establish an age limit. Persons may voluntarily join an insurance fund if their annual in- come is less than 2,500 marks ($595) and if they can be classed as; (i) workmen, helpers, journeymen, apprentices and servants; (2) members of the family of an employer who receive no compensation; (3) petty employers who have either no employees or not more than two employees. The funds may make the right to voluntary insurance dependent on passing a medical examination and limit it to persons below a specified age. The right to voluntary insurance is frequently made use of by in- sured persons who wish to give up their employment for a time in order to secure an extended rest period. Thus in Leipzig the women often have themselves transferred to the voluntary class several months be- fore confinement in order to protect their health during this time and to retain their rights to the maternity benefits at childbirth. DISABILITY PROVIDED FOR The disability for which the insurance provides benefits may be either what is usually understood as sickness, or it may be due to acci- dental injury, including both industrial and non-industrial accident. The sickness insurance system is therefore a system of providing benefits both for sickness and for accidents; it may be described as a system of insurance for temporary disability with a funeral benefit for fatal cases. The disability due to industrial accident is cared for by the sick- ness funds for a period of thirteen weeks, after which the injured per- son is cared for by the accident insurance system. Such cases also are en- titled to the higher rate of cash benefit provided by the accident system after the fourth week of disability and to certain other benefits, both ad- ditional costs being defrayed by the accident insurance. This applies of course only when the patient is included under both systems of insur- ance, which is usually the case. 344 The disability due to a sickness whicii continues longer than twenty- six weeks is after that date cared for by the invalidity insurance system, provided that the patient is included under both systems. Thus a case of tuberculosis receives care from the sickness fund for twenty-six weeks, after which benefits are provided by the invalidity system until recovery or death. Normal childbirth, which is not technically sickness, is also provided with sickness care, as described below ; abnormal childbirth is, of course, sickness and the illnesses of pregnancy likewise receive benefits. BENEFITS OF THE SYSTEM The benefits of the system consist of medical care, cash benefit, maternity benefit and funeral benefit. The insurance laws prescribe the minimum benefits which the funds must provide and then specify the permissive increases over these, as well as certain other additional ben- efits which may be granted if the financial condition of the fund war- rants such action. Cash Benefit. The cash benefits of the system as computed from a basic wage. Usually this is the average daily compensation of the group of persons for whom the fund has been established, but may not exceed five marks ($1.19) per working day. If the fund so desires, it may use a series of wage classes (with six marks ($1.43) as the maximum) or it may use the actual earnings of the member, with the same maximum. The cash benefit consists of an amount equal to one-half of the basic wage; beginning with the fourth day of sickness it is paid for each working day if the member is unable to work, but if the inability to work" begins later than the fourth day, then from the beginning of the disability. This benefit is paid for twenty-six weeks (in case of ac- cident, thirteen weeks) from the beginning of the sickness, or if the pay- ment began at a date later than the fourth day, then from the beginning of the payment. This limit of twenty-six weeks is restricted to any one year; if the same sickness occurs again in the following year, the fund may limit the payments to thirteen weeks in the next twelve months, but if it is a different sickness then the member is entitled to another ben- efit period of twenty-six weeks. The benefit is paid at the end of each week of disability. In case the patient who is given hospital treatment as described below has dependents, the cash benefit is reduced one-half and may be paid directly to the dependents. If the funds so desire, they may in- crease this benefit up to the full amount of the regular cash benefit; they may also pay a member half of the regular cash benefit even if he has no dependents. The extension of the cash benefit which the funds are permitted 345 to make consists of increasing the amount of the benefit up to three- fourths of the basic wage; payment may be made for Sundays and hoHdays and it may be begun on the first day of sickness. If a member becomes unemployed, he retains his right to benefits for three weeks, provided that during the twelve months preceding his unemployment, he has either been insured for twenty-six weeks or has • been a member for six weeks immediately prior to the date of unemploy- ment. The medical benefit must always be provided regardless of the cause of sickness or disability, but the funds, are authorized to refuse the cash benefit, either wholly or partly, if the member has intentionally caused the disability or if it was due to disorderly conduct. Medical Benefit. The medical benefit begins with the first day of disability and con- tinues for twenty-six weeks (in case of accident, thirteen weeks). It consists of physician's services, medicines, and such appliances as eye- glasses, trusses and similar therapeutic aids. In place of these benefits, the fund may provide treatment and maintenance in a hospital or similar institution (medicinal baths, etc.). The consent of the member is necessary if the patient has a household of his or her own, but hospital treatment may be made compulsory if the nature of the sickness demands care or treatment which cannot be given in the house, or if the sickness is contagious or if the patient's condition calls for continuous observation. Hospital treatment includes transportation to and from the institution. The funds may, with the consent of the member, provide care and attendance by nurses or other professional attendants, especially in cases where hospital treatment is advisable but cannot be secured. For such hospital treatment or nurse's service, a reduction in the amount of the cash benefit is made. The question of the choice of physician has always been a matter of controversy in Germany as well as in other countries. The insured persons and the doctors have generally advocated wide freedom of choice of physician by the patient, while the expense of such a plan has always led the officials in charge of the system to endeavor to concert- trate the medical work in as few hands as possible. The plan usually adopted is to make annual contracts with a limited number of physicians, the basis of compensation being either a specified rate per member of the fund or a specified rate per case treated. The competition among the physicians for the position of fund physician has in the past been so keen as to reduce the rate of compensation to a very low level and in a few cases the dissatisfaction of the medical profession with this arrange- ment has led to controversies with the officials of the funds. To meet 346 the wishes of their members some funds have made contracts with a large number of physicians, allowing the patient a wide choice from this panel. In the city of Leipzig, for instance, the number of physicians under contract is very large. The code of 191 1 (section 369) requires the funds to give members the right of choice between at least two physicians unless such choice would cause a serious addition to the costs. If a fund is unable to make contracts on a reasonable basis, then it may,- as a temporary measure and with the approval of the supervisory offi- cials, substitute a cash payment of not more than two-thirds of the reg- ular cash benefit for the provision of medical attendance and medicine. Additional Benefits. The funds are given considerable latitude in regard to the additional benefits which they may provide if they so desire. For instance, the sick benefits may be provided for a whole year; convalescent -care may be given for the period of one year after the expiration of the regular ben- efits ; appliances to prevent disfigurement or deformity may be supplied when such apparatus will aid in restoring ability to work ; special diet such as niilk, eggs, etc., may be furnished; more expensive therapeutic appliances (artificial limbs, etc.,) may be wholly or partly paid for; the members of the family of an insured person may be granted medical at- tendance and medicines. Maternity Benefit. As normal childbirth is not usually designated as sickness, the law specifically provides that women who have been members of the funds for at least six months prior to confinement shall receive a maternity ibenefit equal to the rate of the cash benefit for eight weeks, six of which- must come after childbirth. It will be noted that the prescribed ben- efit does not include physician's attendance, but if the confinement is not normal the case is considered as one of sickness and the regular sick- ness benefits are then granted. If the funds so desire, they may provide medical attendance. In place of these benefits, the funds may provide medical attend- ance, maintenance, etc., in a maternity hospital, or provide attendance by home nurses, deducting for the latter not more than half the maternity benefit. The funds are authorized, if they so desire, to provide a pregnancy benefit consisting of the regular cash benefit, for not more than six weeks prior to the date of birth; they may also provide the services of a midwife and of a physician. The funds may also provide a nursing benefit to insured mothers who themselves nurse their children, equal in amount to not more than half the regular cash benefit, for a period of twelve weeks after birth. 347 Funeral Benefit. The funeral benefit consists of a sum equal to twenty times the basic wage. The funds may increase this sum up to forty times the basic wage or it may use a minimum of fifty marks ($11.90) for this purpose. - The funds may also provide a funeral benefit of amounts smaller than the regular benefit, for persons who are members of the family of an insured person. The right to the regular funeral benefit follows the same rule as the cash benefit in case of unemployment. ■ADMINISTRATION OF THE SYSTEM The administration of the system is based on the fact that the best result is always obtained by having the insured persons themselves, in cooperation with their employers, conduct the insurance under the super- vision of the government authorities. As sickness insurance requires a close supervision of the beneficiaries in order to prevent .malingering, this is best secured by having the members themselves perform it to as great a degree as possible. The insured persons are, therefore, organized into small associations called funds which are for the greater part dis- trict organizations for specified areas, with special organizations for occupations or industries or establishments where such separation gives some advantage either in administration or segregation of risk. These funds cover the whole area of the empire and nearly all of the wage-earning population. At the date of the introduction of the insur- ance there were in operation a large number of small funds many of which were continued under the law of 1883; since that date there has been a tendency to eliminate the smaller funds and combine the mem- bership with the larger organizations. The code of 191 1 enforces this elimination of the smaller funds by rather drastic provisions. Each fund must have a constitution ; in the firsit place it is drawn up by the local authorities for the local and the rural funds after a hear- ing of the employers and of the insured persons ; in the case of an estab- lishment fund, by the employer after a hearing of the employees ; in the case of a guild fund, by the general meeting of the guild in conference with the journeymen's committee. The constitution must specify the name and seat of the fund, the kind and extent of the benefits, the amount of the contributions, the composition, rights and duties of the executive board and of the socalled "committee" (a body of delegates with advisory functions), arrangement of the budget and report on ex- penditures, etc. For purposes of supervision the whole country is divided into dis- tricts, areas which correspond with the political subdivisions. The smallest districts are in charge of the "local insurance offices"; above these are the "superior insurance offices", covering such areas as a prov- 34^ ince, state or even a group of smaller states. The highest supervisory powers are vested in the Imperial Insurance Office, though a few states reserve matters regulated by their own state insurance office. These bodies have the decision as to details of organization, ques- tions as the compliance with the law, the settlement of controversies be- tween funds or their members. They are always composed of govern- ment officials, together with a group of persons, in which the employers and the insured are equally represented. The representatives of these groups serve without compensation, though their expenses are reim- bursed and the workmen members are paid for loss of earnings while in attendance on meetings. These bodies have jurisdiction over the entire field of sickness, ac- cident, invalidity and survivors' (widows' and orphans') insurance. The carriers of the insurance are mutual organizations (with the legal status of a corporation) of the insured persons. At the time of the enactment of the law of 1883 there were in existence a variety of mutual benefit organizations which provided sickness and funeral bene- fits for their members and in a few areas membership in these organ- izations was made compulsory by law. Some of the organizations were of considerable size and many of them had had a long history which had developed a spirit somewhat similar to the "friendly society spirit" in Great Britain. It is estimated that there were about 2,000,000 persons affiliated with such societies in 1883. Because of the attachment of the members to their societies it was deemed expedient to make use of them as insurance carriers in the new national compulsory system, as was done in the more recent British system. Prior to 1914, the following types of funds were in operation: 1. Local sick funds (Ortskrankenkassen) ; 2. Parish or communal sickness insurance (Gemeinde-Kranken- versicherung) ; 3. Establishment funds (Betriebskrankenkassen) ; 4. Building trades funds (Baukrankenkassen) ; 5. Guild funds (Innungskrankenkassen) ; 6. Mutual aid funds (Hilfskassen) ; 7. Miners' funds (Knappschaftskassen) . Under the code of 1911, effective in 1914, the types of funds enum- erated are :• 1. Local funds (Ortskrankenkassen) ; 2. Rural funds (Landkrankenkassen) ; 3. Establishment funds (Betriebskrankenkassen) ; 4. Guild funds (Innungskrmtkenkassen) . Besides these four, this law recognizes the miners' funds and cre- ates a group which it calls "substitute funds." The latter are the mutual 349 aid funds mentioned above. The miners' funds are not changed by the 191 1 law, but the mutual aid funds are subjected to much stricter con- trol with the ultimate plan of inducing them to consolidate with the four groups just listed. The communal sickness insurance was abolished by the new code; the building trades funds also were eliminated and their members, always comparatively few in number, transferred to the other funds. This action was part of the general policy of reducing the types of funds and simplifying the administration of the insurance. A new type of fund, the so-called "rural" sick fund was created as described below. The most important of these types of insurance carriers are the local suck funds, which are separated into two classes, the general local fund and the special local fund. The former is intended to be created in each local district, so that the whole country shall be covered by them ; in cases where it would be advantageous to combine two or more local govern- ment district into one fund, this is done. The new class of fund, the rural fund, covers the same area as the general local organization and where it is desirable, a district may have only a general local or rural fund. The general local fund is intended to include practically all the in- dustrial employees in the area covered by it who are included in the in- surance; under the conditions specified in the law, the insured persons may join one of the other classes of funds, but if they do not, then they rnust be included in the general local fund. A district may have more than one general local fund. The special local funds are those which include persons engaged in one or more branches of industry or kinds of establishments, or the in- sured persons of one sex only. If such a fund was in existence on January i, 1914, when the 191 1 law came into force, then it was allowed to continue operations, provided it met the following conditions ; ( i ) it had at least 250 members; (2) its continuance did not endanger the ex- istence or solvency of the general local or rural funds; (3) its benefits were equal to those of the law; (4) its solvency was permanently as- sured; (5) its area was not larger than that of the general local fund. In general, it was the intent of the 191 1 law to prevent the creation of new special funds of this class. The rural funds are intended to include persons employed in agri- culture, servants, itinerant craftsmen, persons employed in industries where the work is done in the home, and their employees. The federal council may assign to these funds certain other persons. The establishment fund is a carrier created for the employees of one firm or establishment; it must have at least 150 members, though in the case of an inland navigation or an agricultural estabhshment, 50 persons are sufficient. It must not be created if it would reduce the membership 350 of the general local fund below i,ooo members, its benefits must be the same as those of the fund used as standard and its solvency must be permanently assured. A special type of establishment fund must be created temporarily for large construction operations. The guild sick fund is a type inherited from the earlier guild organ- izations of craftsmen ; membership in certain guilds is compulsory even at the present time. The master workmen who are members of a guild may create a fund for their journeymen, apprentices and laborers and these funds must in general comply with the same conditions as ' the establishment funds. When an insured person elects to become a member of a mutual aid fund, or "free" fund as it is sometimes called, he must then pay all of the insurance contributions. This type of fund seems to be gradually disappearing. FINANCES OF THE SYSTEM The cost of the insurance is defrayed by contributions from the insured persons and their employers ; with minor exceptions the former pay two-thirds and the latter one-third of the contributions. The basic wage referred to above is used in computing the amounts to be paid. The state bears the cost of supervision. The law assumes, on the basis of past experience, that contributions at the rate 4.5 per cent of the wages, (3.0 per cent from the insured, 1.5 per cent from the employers), will be sufficient to cover the cost of pro- viding the regular benefits and other permissible expenditures. Provision is made, however, for an increase in this rate where it is found to be in- adequate. If in the case of a rural or local sick fund, a rate of 6.0 per cent is still insufficient, then the local government must pay the amount necessary for the excess ; in the case of the other funds, the employer or the guild must make up the deficit. The employers deduct the contributions of the insured persons from the wages, add thereto the amount of their own contributions and for- ward the amount directly to the sick fund. The members who insure voluntarily pay their own contributions, which are the full amount, with- out any contribution from the employer. The funds are required to accumulate a reserve, which must be equal to at least the average annual expenditure of the preceding three year period. The twentieth part of the receipts is the minimum amount to be added each year until the reserve equals the sum just stated. Aside from this reserve, the current receipts of each year are expected to cover the expenses of each year. The resources of the funds may be used only for the payment of benefits, the accumulation of the reserve, administration expenses and for the general purpose of prevention of sickness. 351 OPERATIONS, 1885-1912 The average number of persons insured during the years given and the number of funds conducting the insurance are as follows :' Number of Sickness Insurance Funds and Number c f Persons Insured, 1883-1913 Year Number of funds Number of persons insured Male Female Total 1885 ' 18,942 20,568 22,508 23,188 23,109 21,659 21,342 3,515,275 5,266,319 7,313,855 9,419,027 9,783,885 9,262,137 778,898 1,313,220 2,206,908 3,650,348 3,835,163 3,955,568 4,294,173 1890 6,579,539 1900 9,520,763 13,069,375 1910 1911 13,619,048 1912 13,217,705 13,566,473 1913 'The number of persons insured is for December 81. To the 13,566,473 persons insured in the funds regulated by the 191 1 law should be added those included in the miners' funds ; the total would then be over 14,000,000. The total population of Germany according to the census of December i, 1910, was 64,925,993; the insured persons, therefore, constitute over 20 per cent of the total population. The occupation census of 1907 .showed that approximately 26,000,000 per- sons were gainfully employed; this number includes many persons in- cluded in special insurance arrangements (government employees, etc.) which have substitutes for the regular insurance system, as well as persons with incomes above the insurance limit, persons in professions, independent shopkeepers, tradesmen, etc. On this basis over 50 per cent of the population gainfully employed is insured and Professor Manes estimates that over 82 per cent of the wage-earners are included. The number of funds in 191 1 was over 23,000; the decrease in the number of funds and persons in 1912 and 1913 was due to the fact that the mutual aid funds were not included in the returns after 191 1. This fact should be kept in mind in connection with the following tables. ''The staitistical data for the sickness insurance system are published in the series entitled Statistik des Deutschen Reichcs; the figures in the summary tables here given are taken frorri volumes 170, 229 and 268. These tables do not include the returns of the miners' insurance, which are published annually in Viertel- jahrshefte sur Statistik des Deutschen Retches. In a few of the tables it has been possible to include figures for 1913. They have been taken from Vicrtel- jahrshefte sur Statistik des Deutschen Reiches, 24 Jahrgang, 1915, Erster Heft, pp. 69-72. 352 The -distribution of the insured persons among the various types- of funds has been as follows: Proportion of Funds and'of Membership in the Different Classes, 1885-IP13 Per cent of total funds in each class Year Com- munal insur- ance Local sick funds Estab- lish- ment funds Build- ing funds Guild funds Reg- istered aid funds State reg- istered aid funds Total 1885 1890 1900 1910 1911 1912 13.7 16.7 14.8 35.4 35.5 37.7 37.6 35.7 40.4 46.3 20,5 20.5 21.8 21.9 29.4 26.6 27.0 34.3 34.3 36.2 36.1 0.3 .2 .2 .2 .2 .2 .1 0.6 1.0 1.9 3.5 3.6 4.1 4.3 17.0 12.9 9.3 5.5 5.3 3.3 2.2 .5 .6 .6 100. 100. 100. 100. 100. 100. 1913 100: Per cent of total membership in each class of funds 1885 1890 1900 1910 1911 .... 13.7 16.7 14.8 12.8 12.5 -13.0 12.7 35.7 40.4 46.3 52.4 53.0 57.2 57.1 29.4 26.6 27.0 25.0 24.9 27.0 27.4 0.3 .2 .2 .1 .1 .1 .1 0.6 1.0 1.9 2.3 2.4 2.7 2.7 17.0 12.9 9.3 7.1 3.3 2.2 .5 .3 100. 100. 100. 100. 100 1912 100. 1913 100 Average membership of each class of func 1 1885 1890 1900 1910 1911 1912 83.5 144.8 . 176.7 209.7 213.5 216.3 216.3 415.6 675.7 966.1 1,441.6 1,523.1 1,607.1 1,654.4 230.4 276.9 339.0 415.1 431.8 459.7 482.0 146.0 266.6 300.0 416.6 448.8 409.5 395.9 111.1 166.2 322.6 369.7 393.1 405.3 406.3 404.8 441.4 586.4 739.3 764.6 303.3 313.8 194.0 265.5 272.2 228.7 319.9 423.0 572.1 597.9 619 2 1913 635 7 The special point of interest in the preceding table is the develop- ment of the local fund; in 1913 over 57 per cent of the membership was included in these and in the future the proportion will probably be still larger. The average size of the funds has steadily increased since 1885 and in the case of the local funds, has increased very rapidly. 353 The gross receipts and expenditures of the system were : Receipts and Expenditures of the Sickness Insurance System, 1885-1912 Year Receipts Expenditures 1885 $15,731,882 27,264,879 49,889,447 105,517,320 116,342,663 119,430,133 $12,529,945 1890 25,668,444 1900 47,264,3-20 1910 100,347,531 1911 111,140,260 1912 114,065,792 The following table which gives the average receipts and expendi- tures per member gives a more adequate basis for estimating the sig- nificance of the increases. Average Receipts and Expenditures of the Sickness Insurance per Member, 1888-1907 Year Dues, en- trance fees and sup- plementary dues Total cost of relief of sickeness 1888 $3 30 3 30 3 71 4 15 5 33 6 05 $2 71 1890 3 04 1895 3 32 1900 3 95 1905 4 94 1908 5 74 The increasing revenue and outlay per member shown by this table require careful explanation in order that false conclusions may not be drawn. Omitting from consideration the sums carried to reserve which have varied, the more important factors giving rise to an increased out- lay per member are five in number. First of all, cost of benefits are based upon wages and these have substantially increased, during the period covered by the table. Secondly, an increasing number of funds have been paid more than the prescribed minima. For example, while in 1910, 88.1 per cent were still paying in compensation of lost wages the minimum of 50 per cent, 9.8 per cent paid more than this up to 66.6 per cent and 2.1 per cent of the funds paid still larger percentages up to the permissible maximum of 75 per cent. Thirdly, convalescent care and other benefits already mentioned have been added, and more liberal medical treatment has been provided. Fourthly', and very important, the minimum number of weeks for which benefits were tO' be paid was in- creased in 1902 from thirteen to twenty-six, and fifthly, in an increasing 23 354 number of cases the funds have voluntarily adopted rules for the ex- tension of benefits for more than the minimum weeks. In 1910, the miners, excluded, there were 23,188 funds, while 22,341 of these pro- vided benefits for the prescribed twenty-six weeks only, 249 extendeci them for more than twenty-six weeks up to thirty-nine, 585 for more than thirty-nine up to fifty-two weeks, and thirteen in some cases con- valescent care) for more than a year. As typical of the operations of the system, the fpllowing state- ment shows the various items of expenditure for 1912 : Expenditures of the Sickness Insurance System, 1912 Class of expenditures Amount Per cent Medical treatment Medicines , etc Cash benefit: (a) For members (b) For family of members Maternity benefit and pregnancy benefit Funeral benefit ' Treatment in hospitals, etc Convalescent care Payment to others for benefits provided Advances repaid Dues , etc. , repaid Investments purchased LxDans repaid Cost of administration All other Total $20, 13, 34, 1. li 1, 12, 18 ■1 5: 1, 380,725 020,038 466,339 328,490 715,088 888,035 745,733 78,179 220,500 77,785 114,799 115,508 853,717 140,414 925,492 $114,065,792 17.8 11.4 30.1 1.1 1.5 1.6 11.1 0.1 1.1 0.1 0.1 15.8 1.6 4.5 1.7' 100.0 Nearly a third of the expenditure is for the cash benefit; medical service, medicines and hospital treatment, etc., together make up over 40 per cent of the expenditure. The maternity and pregnancy benefits formed only 1.5 per cent of the total while the cost of administration by the funds was 4.5 per cent. The cases of sickness and their duration are given in the following table. Attention should be called to' the fact that the cases of sickness include cases of accident. In the Leipzig Local Fund, the industrial acci- dent cases formed about 8 per cent of the total. 35S Number 'and Duration of Cases of Sickness for which Benefits were paid, 1885-1912 Cases of sickness Days of sickness Days of sickness per case for which benefits Year Number Average number per 100 members Number Average number per 100 members were paid Male Female All mem- bers 1885 1890 1900 1910 1911 1912 1,804,829 2,422,350 3,679,285 5,197,080 5,772,388 5,633,956 42.0* 36.8 38.6 39.8 42.4 42.6 25,301,178 39,176,689 64,916,827 104,708,104 115,128,905 112,249,064 589.2* 595.4 681,8 801.2 845.4 849.2 14.1 16.0 17.0 18.9 18.7 18.6 14.1 17.2 20.1 23.9 23.7 23.7 14.1 16.2 17.6 20.1 19.9 19.9 * Computed on number of members on December 31. The table indicates that for every lOO insured perspns, approximately two-fifths have received benefits during the year. The days of sickness for which benefits were paid have come to be nearly 8.5 per member — m other words each member must provide sufficient income to the fund to pay eight and one-half days of benefits. The last column in the table is perhaps the one most frequently referred to. It indicates that there has been an increase in the benefit payment for cases of sickness. The usual reference to this column fails to take account of the fact that it refers to the number of days for which benefits were paid and does not mean the actual duration of the case of sickness. Thus the law of 1902 increased the minimum benefit period from 13 to 26 weeks and included sexual diseases in the class entitled to benefit. These changes naturally affected the average duration of a case of sickness. Thus in 1902 the average duration was 18.8 days, while in 1904 the same figure was 19.7 days. Then too, as already stated, provisions have been made beyond the prescribed period in an increasing number of cases. It will be noted, however, that since 1904 the average duration of a case has re- mained fairly constant. It is, therefore, not a valid deduction to infer that this increase is due to malingering. CONCLUSION It is not easy to appraise the value of a system of this magnitude, but the outstanding fact is that it has been in actual operation for more than thirty years and that the only changes made in it have been in the nature of extensions. Like all social institutions, it is not without its critics, who have continually emphasized the heavy cost to the in- dustries of the country and who have claimed that the effect it has had on the wage -earner has not been beneficial. Criticism has also been made of the small amount of the relief provided in any one case. 3S6 The burden which the system imposes on the industry and on the wage-earner can be roughly guaged from the maximum rate of dues, namely 3 per cent of wages and one-half of this rate from the employer. The industry has, therefore, as a rule to add not more than 1.5 per cent to its pay roll for sickness insurance. The charge in the Leipzig Local Fund is 2.7 per cent of wages to the insured persons. Obviously a more accurate method of representating the burden would be by expressing it in terms of the value of the product. In certain industries, such as stone- cutting, wages make up nearly 90 per cent of the cost of production, while in others such as textiles, wages make an extremely small part of this cost. A number of studies have been made on this subject, though for present purposes they are of little assistance because they "give only the total cost for all three branches of insurance without stating the figures for sickness separately. Dawson (Social Insurance in Germany) states that the cost to the association of Colliery and Smelting Works Owners of Upper Silesia on account of sickness insurance in 191 1, was eight cents per ton of product. In many lines of industry the total cost of all forms of insurance does not exceed one per cent of the value of the product. During the thirty years of operation of the insurance laws, the share of Germany in the world's exports has increased while the statistics of the invalidity insurance show that there has been an increase in the proportion of persons in the higher wage classes and a corresponding decrease has occurred in the proportion receiving the lower wage rates. The criticism that the amounts paid, by the insurance system are small, can only be answered by i)ointing to the cost, which is correspond- ingly small. Much has been made of the criticism that the insurance laws have produced a national tendency to enlarge upon every trivial sickness and to demand benefits upon every possible occasion. It is also a fact that during seasons of unemployment, particularly during the winter months in the case of the building trades, the sickness claims at once increase. There is of course considerable truth in these statements ; a universal system of insurance includes both the honest and dishonest and the latter make use of opportunities in this field as in others. As the administative authorities are familiar with this tendency they take steps to combat it by having medical and other inspectors to supervise the beneficiaries. A tendency for the system to become more bureaucratic is also evi- dent. It is due in part to the gradually increasing membership in each fund, so that the individual members no longer have the same personal interest in the affairs of the organization. The British departmental com- mittee on sickness benefit claims found the same tendency under the British law and spoke with regret of the "loss of the old friendly society spirit." All of the available evidence, however, tends to show that both the 35? Employers and the wage-earners regard the system, in spite of its im- perfections, as of great value and on the whole bear the charges for it willingly. While the Socialist members (the labor members) of the Reichstag voted against the first sickness law, they have strongly sup- ported all subsequent laws enacted. While the cost of the three systems of insurance makes a substantial sum each year, there has never been a demand for their abolition. APPENDIX D HEALTH OF OHIO COAL MINERS Emery R. Hayhurst, Ph. D., M. D., Consultant in Industrial Hygiene, Ohio State Department of Health. INTRODUCTION The health of coal miners in the United States remains a matter of considerable doubt and uncertainty. According to a summary of liter- ature and experience in this country made (1918) by a prominent vital statistician, there exists a large amount of superficial information which should be replaced by more trustworthy data. This does not include the reports of the United States Bureau of Mines and associated institutions relating to working conditions, especially ventilation, temperature and humidity, explosions and sudden disasters accompanied by asphyxia. There has been no attempt to separate mortality statistics of hard and soft coal miners. In the Survey of Occupational Diseases made by the Ohio State Board of Health in 1913-1915, the mining industry was not included. The Ohio Health and Old Age Insurance Commission assigned this investigation to the author in order to get a better knowledge of the status of health, vital statistics and the administration of sanitary regula- tions in the coal mining districts. The field work was done in coopera- tion with the State Department of Health, through the Division of In- dustrial Hygiene of which Dr. R. P. Albaugh was director. A similar investigation was made by the writer in Illinois for the Illinois Health Insurance Commission in conjunction with a representative of the Illi- nois State Department of Health. Only bituminous or soft ct)al is mined in Ohio. The importance of the industry is indicated by the fact that in 1917 the' total number of employees as reported by the Statistical Department of the Ohio Indus- trial Commission, was 49,919. The total production of coal for the year was 41,677,986 tons. The Ohio output comprised 7.6 per cent of the total amount of the bituminous coal produced for the country in 1917, the leading states being Pennsylvania, West Virginia and Illinois. In 1917, 30 counties in the state produced coal. Reports show that the industry is constantly on the increase in spite of occasional fluctuations, and that there is enough coal in Ohio to last for several centuries, mak- ing due allowance for the stable increment in the rate of mining. (358) 359 "The coal fields of Ohio lie in the eastern part of the state, extend- ing from near the shore of Lake Erie in Geauga and Lake counties south- westward to Scioto and Lawrence counties on the Ohio River. An area of about 12,650 square miles, nearly one-third of the state, is underlain with coal bearing rocks." Sources of Information. The investigators conferred with the officials of the State Mining Department; with Mr. G. W. Savage, district secretary for the State of Ohio of the Uijited Mine Workers of America, to which all Ohio miners belong (with the exception of one mine) ; with Dr. A. W. Freeman, commissioner, and Mr. James E. Bauman, assistant commissioner, of the State Department of Health; with the officials of various coal com- panies ; with the district mine inspectors ; with physicians in coal mining communities, and with many others. The answers submitted by the 12 district mine inspectors to questionnaires and in conferences were com- plete for all districts and full of valuable information; they summarized whole districts where the investigator's were enabled only to visit certain representative places. The itinerary for the investigation included representative centers in each coal district of the state, excluding the almost exhausted District No. ^''II with Massilon as its center comprising the northwest corner of the coal field. Mine inspectors, mine managers and others were inter- viewed in connection with 43 mines which were visited. Table I shows at a glance the dififerent sources from which information was obtained. 36o Table L Sources of Information. District number ' Principal city or cities in district No. coun- ties in dis- trict'' Counties included in investi- gations Total num- ber of mines No. of mines vis- ited Total num- ber of miners (1917) No. of men at mines vis- ited No. of physi- cians inter- view'd I Jackson Ironton 5 Jackson .... Vinton 174 5 2,929 209 4 II III Nelsonville . . f Athens ( Pomeroy Zanesville . . . Cambridge ... f Coshocton ^ New Phila- [ delphia Massillon f Steubenville t Bellaire ..... Salem Total 1 2 3 3 3 7 4 2 Hocking .. . Meigs Athens 77 155 9 5 2,623 9,306 11,514 890 5 4 IV V VI VII Perry Guernsey .. Coshocton . Stark" Belmont ■ Jefferson . . . Harrison Columbiana 148 65 177 104 258 51 1 12 3 5 3 4,687 5,354 3,902 1,285 18,854 979 100 1,647 233 1 3 1 VIII, IX X, XI XII 1,194 285 2 3 30 1,209 43 49,919 8,072 22 We have followed the division used by the State Mining Department. The first seven and the 12th districts constitute the region of previous maximum pro- duction but are now becoming exhausted. The/ eighth to the 11th districts are at present the maximum producers. Great quantities of coal are still untouched. Of the total numlber of miners in these four districts, 12,079 are in Belmont county alone. Practically all the coal from these four districts comes from the seam known as Pittsburgh No. 8. ' Since the coal districts are divided by railroads rather than by counties, the figures for the number oT counties in this column do not correspond with district boundaries in all cases. " Stark county was covered in a school survey by the writer- in 1915 during which time the local mines were noted. The ten chief producing counties are shown in Table II. Table 11. Chief Coal Producing Counties, ipi7. County. Tons pro- duced in 1917 Belmont . . Athens . . . Jefferson . Guernsey . Perry Hocking . . Tuscarawas Meigs .... Harrison . Jackson . . 11 6 5 4 2 2 1 1 1 1 ,156,666 ,313,619 ,742,240 ,024,265 ,445,114 ,211,858 ,788,800 ,267,144 ,222,561 ,016,249 36i Mortality statistics are not collected for Ohio coal miners by any agency. In Illinois, it was possible to obtain information from the deaths claim insurance maintained by the United Mine Workers of America, which inquires carefully into the causes for the deaths of all miners. Summaries from these will be given later in this report. The Method of Selection. The selection of mines was made in order to lay stress on older districts and to include mines of large, medium and small production; those adjudged by district mine inspectors and others to be good, fair and bad in respect to working conditions. The investigators chose typical examples of housing conditions and made a study of the various methods used in mining communities to cope with sickness and death. At first they traveled by train to mining cen- ters, then hired automobiles to the mines. This method proved too slow and costly and the work was later carried on entirely by automobile from Columbus, Much of the mining field is in hilly regions, difficult to tra- verse. The field work extended from June i8th to July iSth, and from August 20th to September 15th. The intervening weeks were spent in a similar inquiry in Illinois. When necessary, further information was obtained by questionnaires and conferences. The number of mines with their average number of employees is shown by Table III. Table III. Number of Mines Reporting with Average Number of Employees, igij Average number of employees Number of mines reporting Less than 10 592 10 but under 50 345 50 but under 100 102 100 but under 20O 92 200 and more * 76 Total 1,207 *The largest number of employees at any one mine during the time of our investigations was 488. 362 WORKING CONDITIONS The drift or slope mine comprised 1,108 of the total 1,223 mines in operation in the state in 1917. The room-and-pillar style of development is the typical one. There is a slight dip in the general coal field toward the southeast which in the average mine equals 27 feet to the mile. Long- wall mining, in which ventilation is a little easier to maintain, occurs at but one mine, that of the La Belle Iron Works at Steubenville. Shaft mines are 117 in number. Ohio is considered a locality of shallow min- ing. This is due to the fact that the coal field lies on the western edge of the Appalachian coal trough whose seams outcrop sooner or later as they approach the western margin of the coal field. Mines vary in depth from those upon the surface, which are simply stripped to 275 feet at the foot of the deepest shaft mine. All geological seams from Numbers I to IX are worked, including a couple of intervening seams. The deepest known seam is designated as Number I. In addition to the II main seams, eight others are occasionally mined at favorable places. The distance to the working face in older mines amounts to as high as four and three-fourths miles (Rail and River Mine, Belmont Co.) from the entrance. The power used for hoisting in shaft mines is usually elec- tric, but many mines use steam. Small drift mines use animal or man power. Haulage in bigger mines is principally by electric motors with mules or ponies for terminal work. Only a few mines have barns located below ground. Mining machines under-cut 85.7 per cent of the coal pro- duced, the balance being pick mined. The number of employees in ma- chine mines in 1917 was 42,996; of employees in pick mines, 6,923. In Illinois, the two types of mining are more nearly equal. The chief blasting substance used is black powder, ranging in size from 26/64ths (CC) to 9/64ths (FF). Very little so-called "permis- sible" explosive is used. Dynamite is used occasionally for "horse-backs" or boulders; also, rather extensively in the few large stripping mines. Shooting down of coal may be done at any time of the day except where local mines have forbidden such practice. One mine inspector said that no shooting was allowed during work hours in his district due to an agreement between the workmen and operators. There is no state law covering the time for blasting coal. As a class, Ohio mines are wet mines. Frequently there is dripping from overhead and mud under foot more or less throughout the mine. This is because they are largely shallow mines. Some of the deeper mines are quite dry and have to resort to the sprinkling of roadways in order to prevent explosions following dust courses. The chief mine gases are of three types: fire damp (methane, CH^) which is explosive but not dangerous to health ; black damp (where carbon dioxide and nitrogen are increased at the expense of oxygen) ; 363 and white damp (carbon monoxide). The first two damps occur naturally in mines and artificial ventilation, promoted by means of large blow fans or furnaces, is necessary to keep the per cent of gas sufficiently low to prevent explosions and supply enough oxygen to the workmen for breathing purposes and for burning of lamps. The state mining laws specify detailed regulations concerning the artificial ventilation of mines; and usually a high degree of efficiency in ventilation is main- tained through careful inspection and the employment of mine examiners by the operators. Small mines use natural ventilation with success. The mines in various parts of the state, such as those around Athens and Cambridge, tend to produce fire damp with an occasional' explosion resulting. On the whole, Ohio mines are not considered very "gassy" (so far as fire damp is concerned) ; they do not compare- with British mines, and are not as bad as some of the Illinois mines in this respect. There is no mine in the state in which safety lamps have to be used exclusively, which is characteristic of many British mines. White damp occurs in mines in connection with fires and explosions and the blasting of powder when the air supply is insufficient. It is al- ways, the result of incomplete combustion. It forms a dangerous com- ponent of "afterdamp" which occurs after fires, etc., and which has rather more effect on canaries or mice than upon men so that the former have been used as test animals. Collections of this gas are insidious and the miner has no ready means of detecting it. Many Ohio miners suffer from it because of the constant shooting which is allowed during work hours. "Feeders" or "blowers" of illuminating gas, such as those used for domestic purposes, are little known in Ohio. Gasoline locomotives, such as exist in some Illinois mines, are not allowed in Ohio mines, prin- cipally because of the pollution of the mine air by the dangerous exhaust fumes characteristic of gasoline motors. Miners usually work in pairs in two or more rooms and a special feature of ventilation is to split the air currents entering the mine in order to distribute fresh air evenly to these rooms. The law requires that no men be allowed to work in rooms or advancing entries more than 60 feet "ahead of the air," which means the distance^ from a definite air current of given volume. An effort is made to keep this air current equal to 150 cubic feet per man per minute (with 50 cubic feet increase in gassy mines) and 500 cubic feet for each animal. The temperature of mines is very constant. Shallow or wet mines are the coolest (temperature falling between 50° to 60° at the working face). Mines between 300 to 600 feet deep have temperatures ranging from 60° to 70°. Slight seasonal variations occur. The air always in- creases in temperature as it passes through the mine. The humidity of mine air is invariably high since even air carrying minimum amounts of wa:ter vapor into the mine, as in the winter time, leaves the mine nearly saturated after having absorbed moisture out of the coal and strata. 364 Hence the physical condition of mine air, with the exception of dust, is ideal for work. The chemical condition is rendered so through close obedience to the mine laws on ventilation. Dust stands as the chief bane of coal mine air for the vast majority of miners and from a health point of view, its varying composition from coal dust to granite dust is in proportion to its danger to health. Pick miners, machine men and loaders, (i. e. workers at the face) and tipple men are especially exposed. Practically all mines are infested with rats or mice, sometimes both. In the absence of epidemics such as plague, they have little significance as a health hazard to miners. Insects in mines exist only as gnats or small flies, few in number and consequently of small menace. Mosquitos invade drift mines for a few score of feet only. When sanitary privies are absent on the surface (which is the invariable rule), these and other insects are a great menace as the carriers of disease from excrement to food. For the year 1917, out of the total of 49,919 employees at the mines in the state, 43,637 worked underground. The eight-hour day is uni- versal, although some company men may work as long as ten hours. Overtime is very infrequent. Small night shifts are employed at some big mines. Absenteeism averages about 10 per cent per day and this percentage is about doubled for a day or two following pay day, which occurs twice a month. Injuries cause about 2 per cent of total absences. Labor turnover is much more pronounced in large mines and mining centers, and amounts to from 2 to 30 per cent per month. In the large producing districts, foreigners make up from 70 to 90 per cent of the employees. These consist of fairly equal proportions of Austrians, Hungarians, Italians, Poles, Slavs, Belgians, Russians and other eastern and southern Europeans. Colored employees are found in small numbers and then in only a few mines. Britishers are frequent in older districts. An inquiry into ages of 4,793 employees (inside and outside work- ers) at 34 mines visited showed 0.6 per cent over 70 years of age; 2.7 per cent between 60 and 69; 87.0 per cent between 22 and 59; and 9.7 per cent between 16 and 21. It was found that for the past two years mines have been working very steadily and that during the past year shortage of railroad cars for hauling coal has constituted the chief cause for shutdowns. Occasion- ally epidemics of the grippe have limited a mine for a few weeks here and there. At the present writing, reports show that mining districts have been hit very severely by the influenza epidemic, many shutting down entirely. Celebrations and funeral observances cause shutdowns of a day at a time several times a year, and in some respects the large mines suffer most frequently. While sickness could not be discovered as a 36s cause, still the part days taken off by great numbers of workmen are probably, more necessary to health than is usually thought. Transportation to and from the mines is difficult because of the hilly character of the country. Some mines are practically inaccessible by automobile; many lie from four to seven miles from inhabited com- munities and are very difficult to reach. Different methods of transpor- tation are utilized : mine trains, special conveyances and horses and buggies. The mine inspection system of the state is chiefly concerned with the prevention of accidents, especially explosions, fires and asphyxia- tions; and with the compilation of statistics. For convenience the state is divided into twelve districts, the first seven constitute the western two- thirds of the coal field and are numbered from I in the south to VII at the north; the five remaining districts compose the extreme eastern and northeastern portion of the coal field and are numbered from the south (Nos. VIII, IX and X) to the north (Nos. XI and XII). Each dis- trict has been provided by law with a full time mine inspector, but one of the largest districts during the time of the survey was unable to fill an existing vacancy. County mine inspectors do not exist as in Illinois. In addition to these inspectors, each mine has one or more mine examin- ers paid by the company. At present the inspection system is plainly short of man power. This provision for coal mines redounds as much to the general health as to the prevention of the disasters mentioned. Wages were good at the time of the inspection and with steady work and the larger pay envelope, poverty and pauperism were practically un- known. In previous years because of extensive strikes and the lack of a demand for coal, most mines have been shut down for many months during the year. In Illinois where the same conditions have prevailed the Springfield Survey in 1915 found that many mining families had great difficulty in making ends meet throughout the year. The same situation exists in Ohio. The 43,637 employees within the mines for the year 191 7 were divided as follows : Pick miners 5,763 Inside day hands 10, 175 Loaders, drillers and shooters 23,900 Machine miners and helpers 3,799 Total 43,637 The outside workers totaled 6,282. Investigations showed the health hazards for various occupational designations to be as follows : Cagers and those who work around the bottom or the exit of the mine, breathe the air after it has made the complete circuit of the mine, provided the return air is by way of the hoisting shaft or the exit road- 366 way, which is tisually the case. The air movement is also brisk, Fine dust is a feature. Humidity is high. Getting wet with water drippings is almost unavoidable. Drivers, including motormen, trip-riders and mule or pony men, are usually youths. The work is muddy, often dusty, in strong drafts and quite hazardous in regard to accidents. Laborers are scattered about over the mine and have the hazards of the places in which they happen to work. Loaders are subjected to air conditions of the distant interior work- rooms, and to immense amounts of dust. Their work is laborious, on the tonnage basis, and when slack periods exist they are apt to sit around in cool, damp places. Machine men have the ventilation hazards of the workrooms and are most subject to breathing fine dust (bug dust). Most of the work is laborious and in strained attitudes. The work of pick miners is much less difficult than before the days of the extensive use of powder. They have the ventilation hazards of the workroom and a severe dust hazard. Their work is laborious, on the tonnage basis and rather monotonous, with considerable jar, much active work is intersperced with spells of waiting for mine cars when they sit around in cool atmosphere and damp places. Timbermen are exposed to the ventilation hazards of workrooms and entries, more or less dust, and more or less wet work in many mines. Trappers spend much of their time in waiting at the switches or at the doors which they watch. They may be in strong drafts carrying various amounts of dust. They are usually youths, sometimes old men. Tipple men have the hazards of weather exposure at the surface of the coal mine; a great deal of coal dust; occasionally, also, smoke and fumes from the burning dump piles where these exist. The weighmen are usually in enclosed quarters. Track men have weather exposure, and the breathing of a great deal of coal dust. Hoisting engineers are exposed to excessive temperatures (ioo° to I40''F.) where steam hoists are used — particularly dangerous, since these men must be constantly on the alert, because, with their levers, they guide the raising and lowering of cages by means of signals from bells or whistles. Child labor has been practically eliminated from Ohio mines. Youths, under sixteen are prohibited by law from entering a mine. One hazard remains when youths begin work in mines without preliminary physical examination to determine their fitness for such work. Stripping mines. The chief health hazards are weather exposure,, particularly heat in the summer while working in low places. Also men in steam shovels are considerably exposed to heat from furnaces. Some risks from blasting powder, fumes and dynamite also exist. 367 Coal washers undergo weather exposure with wet work and a great deal of dust from the crushing processes. Noise is a marked feature. Some Special Hazards.- Illumination. Illumination is no longer a hazard for miners be- cause of the common use of electric lights and the modern carbide lamps. Oil lamps are all but gone. Safety lamps, with their imperfect illumina- tion, are not required in Ohio mines. Heat. As a rule Ohio miners are not exposed to high working tem- peratures, although steam hoisting engineers may have undue exposures. Cold. The temperature of Ohio mines is invigorating. As long as workers keep active the low temperatures are no hazard. Humidity. Dripping roofs, mud and dampness characterize most Ohio mines. Fatigue. The chief hazards of fatigue involve faulty postures ; work of a jarring or vibratory character; heavy lifting and straining and a certain percentage of men ill fitted physically for the work. Hours of work. The eight-hour . day, with very little overtime ob- tains at mines. Some company men (laborers) work ten hours. Infections. The disposal of stools in the gob as is the prevailing method, can be made safe. The extent to which coal mine dust may transport virulent germs, as from spiting, has not been investigated; the hazard is probably insignificant. Diseases from animals, such as anthrax, glanders and lockja^y, do not seem to exist. In the presence of the black plague the rats and mice in mines would be a great menace. Injuries which miners receive are at least as free from secondary infec- tions, if not more so, than in most classes of workers. Electricity. In addition to burns and shocks, and occasionally elec- trocutions, the witnessing of brilliant electric flashes occasions some electrica ophthalmia (a painful swelling of the eyes which may persist up to 14 days). Poisons. These concern mine gases principally (q. v.). Sulphur occurs as pyrites and in acid forms, the latter dissolved in water and often strong enough to eat holes in clothing or to cause ulcers in the eyes. Assuaging of thirst. Questionable water supplies in many instances expose miners to typhoid fever, dy&entery and water borne diseases. Alcoholic beverages are not permitted while at work. Personal hygiene. Miners are in great need of instruction in mat- ters of personal hygiene and the prevention of sickness. A large num- ber of their illnesses could be curtailed by this means. General Sanitary Conveniences. Wash houses. Unlike Illinois, few mines in Ohio are equipped with wash houses or change houses. This feature is emphasized by a state 368 law in Illinois for all industries. Here and there in Ohio a few men group together and build and equip a shanty. Private persons some- times do this and a charge of 25 cents to $1.00 per month is made for its use. However, at a few of the larger mines, wash houses have been built and maintained by the operating company. The workers supply soap, towels and locks. Shower baths are very scarce. Empty powder cans, tubs or basins are the rule. Water for bathing is usually carried to the wash house by hand. Hot water is apt to be absent at electric mines. Drainage from wash houses is frequently dangerous to water supplies. By tradition, miners bathe completely every day where the opportunity is offered. This means that in Ohio it is usually done at home. Often the miner builds a shed in his yard in which to wash. Statistics show that the properly equipped wash houses at mines are used by upwards of 90 per cent of the employees. The absence of a place to wash up after work was commented upon by many physicians as a potent cause for rheumatism, colds and pneumonia in miners. (The United States Bureau of Mines has made a special study of wash and change houses in Technical Paper, 116). Clothing provisions. Quarters in which to exchange street clothing for work clothing are not provided at Ohio mines as a rule. Where wash houses are present, a place to hang clothing is usually at hand. Nails and pegs are driven into the walls of a shanty and lockers are found about as often as ceiling hooks or hangers upon which clothes are hung and pulled up to the ceiling by means of a pulley and rope. Over- crowding is common. Screens against flies and other insects are rare. (The ideal arrangement is a room partitioned off from wash quarters, equipped with ceiling hooks for work clothes and lockers for street clothes.) Water Supplies. Water for drinking purposes is usually not obtained at the mine but is brought by the employees in their lunch buckets. Wells in the neighborhood of the mines, although in very poor sanitary condition, are the usual sources of water for drinking purposes. Scarcity of water is serious in some districts. Much of the t3fphoid fever, dysentery and other sickness in mine districts is due to lack of attention to the source of drinking water supplies. Hypo-chlorite disinfectants could be pro- vided at small expense at every mine. Seivage Disposal. Mines do not have toilet facilities below ground. The men at work simply use the gob piles. In dry mines there is little hazard from this practice, provided care is taken by each miner to cover his stool. In many mines portable trench buckets, or closets mounted on trucks, could be used. At the surface, where from a few to 50 men are always em- 369 ployed, the vast majority of mines provide nothing in the way of a latrine, much less a sanitary one, for the workmen. Instead, the latter usually seek the neighboring dirt piles, fields, timber or hillsides. On account of this lack, the flies and insects about mines and mining towns are special menaces as disease carriers. A standard privy for the sur- face workers at a mine could be constructed at very little cost. Lunch Provisions. Each employee at a coal mine invariably carries his own lunch in a specially constructed miner's lunch bucket, which is provided with a water compartment. The thirty-minute lunch hour prevails. Occa- sionally workmen at the surface may have opportunity to lunch at home. HOUSING CONDITIONS AND LOCAL HEALTH ADMINIS- TRATION. The community has a large place in determining the diseases of miners. Very often the chief afflictions are favored by insanitary hous- ing conditions, unsafe water supplies, sewage disposal, food supervision and lack of efficient local health administration. The attitude in America concerning community health is invariably to "put it up to" the community itself, and as long as communicable diseases are not spread to neighboring communities to such an extent as to raise protest, very little attention is given to health by any locality. Contrary to usual be- lief, the rural community is quite universally the most unhealthful place in which to live. The hygiene and sanitation of housing is important since it involves about one-third of the normal day for the worker and most of the time for his family. While some Ohio mines, for instance, those at Athens, Porneroy, Bellaire and Nelsonville, are located in or close to cities ; as a rule, mining towns are composed of a store or two around which very plain frame dwellings or shanty houses exist. There are one or two model communities, such as the one at Bradley, a model in regard to building construction, arrangement and upkeep, but safe and sanitary standards for. both water supply and sewage disposal were nowhere en- countered. The typical mine town consists of rows of dingy houses, built after one or two patterns, located-on hillsides, with rows of privies located close to wells or draining toward the wells on the next street''. Rarely any attempt at garbage collection exists. Often small ditches of ■' Jopeph H. White, "Houses for Mining Towns,'' United States Bureau of Mines, Bulle'An S7. This 64-page bulletin, replete with illustrations and diagrams, covers the sub'ect of sites and arrangement of towns, types of houses and their construction, the yard and its* appurtenances, water supply and sewage and refuse disposal. 24 370, water act as open sewers. Screens for houses are usually provided by the occupant if present at all. , At practically all mines with company houses some workers have bought or are buying their homes. The company erects them for rent or sale and they are sold on very easy terms to the miners. Here and there additional houses or a small town has sprung up around the com- pany houses. Building syndicates have erected many miners' residences and rent them, receiving this rent by a check from the miner's pay at the mine. Great complaint was frequently heard of the lack of re- pairs to render them habitable. Miners' houses usually contain three to five rooms and are of the story-and-a-half type. Rentals average about $2.00 per room. A great number of mining companies have built from four to 12 houses and then have allowed the balance of the com- munity to build for itself. The township board of health or a health officer is the usual super- visor of small towns and outlying communities, such as coal mining dis- tricts. SICKNESS : TYPES AND EXTENT There are two methods of inquiring into types and extent of sick- ness : first, statistics ; and second, opinions of persons qualified through experience or practice to impart information. Practically no statistics are available concerning sickness among Ohio coal miners. The bookkeeping of vital' statistics has not extended this far. Some of the local unions and benevolent associations can sup- ply certain limited statistics but these are too local to warrant drawing conclusions therefrom. Hospital statistics in mining districts are not representative, however complete they may be, since an unknown per- centage of miners go to hospitals when sick. No insurance companies have so far taken out group policies covering sickness or disability among miners. We must rely chiefly on physicians in mining centers for the infor- mation desired. The experience and opinions of physicians, scattered throughout the district, particularly where they concur, are probably more apt to represent a close analysis of the sickness situation than any con- clusions which might be drawn from statistics. The following is a sum- mary of statements, covered by the questionnaire by which physicians were interviewed personally in mining communities: Diseases rarely found among miners. Certain diseases reputed to be prevalent among miners elsewhere or to be suspected', were found to be practically absent among Ohio miners. These are lockjaw, anthrax, gland'ers, hookworm, rat-bite disease and nystagmus. Diseases found less frequently than usual are pneumonia (except among negro miners where it seems to be more prevalent) , tuberculosis (that which occurs is generally of a very slow progressive type, difficult to separate from miner's asthma), and venereal diseases. Mortality sta- tistics (Illinois coal miners) on pneumonia and tuberculosis are not so favorable as physicians' reports would indicate. Diseases having the usual frequency. Acute rheumatic fever; afflic- tions in the upper respitory tract, such as colds, tonsillitis, middle ear diseases, nose, throat and sinus affections; acute bronchitis; eye afflic- tions, although the communicable disease, trachoma, or granulated eye- lids, was f renquent in some localities ; skin affections ; foot affections ; def oimities ; nervous affections ; hernias ; varicose veins ; other chronic diseases in general and malaria. Epidemic diseases such as influenza, smallpox and summer diarrhoea are usually worse than in the rural village. Diseases with occupational earmarks are "rheumatism", asthmatic afflictions, and afflictions due to alcoholic beverages. The "rheumatism" is of the type unassociated with fever, called musculo-articular, of which lumbago is the chief form, and so-called "sciatica", the next. It tends to develop after prolonged exposure to cool damp atmospheres, drafts, ' the weather and straining- efforts on the part of men not physically adapted. Asthma is a decreasing disease ; probably bad ventilation still plays the chief part in its cause, but the presence of dust and physical disability — ■ weak hearts or chronic disease — are prime factors. Asthma is rarely found in individuals under 40 years of age and occurs in about one or two working-men in a hundred. Conditions of the work place frequently occasion temporary absences. Alcoholism is ex- ceedingly common, perhaps more so than in other industries, since it seems to be a tradition among a considerable number of miners that a day or so after each pay should be devoted to an alcoholic debauch. Less serious hazards are dust plugs in the ears (of no consequence but cause some temporary deafness) ; eyes flashed by electric short circuits ; callosities on knees and sometimes elbows, hands and shoulders, mostly in "low coal" districts; "gassing", due principally to accidental breath- ing of white damp after blasting, fires or explosions; and premature ageing, — this not a marked feature. There is some eye irritation due to sulphur (pyrites) dust. General surmnatry of diseases. There is no reason for believing that the usual afflictions, outside of the respiratory system and the musculo- osseous system, are more frequent among miners than among other em- ployees. In fact, they are, as a class, probably healthier than the aver- age type of factory worker. Top workers, exposed to the weather, are said to have more sickness than those in the mine. Sickness is much more rampant among the women and children in mining districts than among the men. Alcoholism is perhaps the most serious factor among the social problems. It was said to be on the decrease, — explained by nne nhvsirian as due to education, increasing cost of alcoholic drinks. 372 / piratory afflictions, clironic bronchitis associated with asthmatic symp- toms, and 'often complicated by a chronic form of tuberculosis, is un- doubtedly more prevalent than among agriculturalists. MORTALITY Mortality statistics for Ohio coal miners have never been compiled. Neither the State Bureau of Vital Statistics, the state miners' organiza-- tion, nor any other institution has published the death rates from various causes for Ohio miners. To be of value, these should be obtained for a period of several years. Something may be gained from the result of figures compiled for Illinois coal miners where the state miners' organi- zation keeps a careful record of each coal miner's death in its death claim insurance department; and by which a burial fund amounting to $250 is paid to the beneficiary on the occasion of the death of a miner. There is no reason to believe that death rates among Ohio coal miners are materially different or better than those of Illinois. A summary of tables and statistics compiled for Illinois miners during the past summer follows. I.' The death rate of Illinois coal miners has been constantly on the increase since 19 12, the year for which the first figures were obtained. In that year the death rate per annum per 100,000 employees was 1,003 > the death rate for 1917 was 1,167 a-nd for the first six months of 1918 it was 1,185. II. Violence, exclusive of suicide, constituted 36.8 per cent of the causes of death, among 5,428 deaths among Illinois coal miners, 1912 to 1918. This rate is 2.3 points Jess than for "miners and quarrymen" in the county at large (registration area, 1909). This cause, however, is greatly in excess of the general average of all deaths from violence, which is 10.6 per cent for "occupied males" in the registration area, 1909. Only one other occupation, "steam railway employees'' surpasses miners in the high rate of death from violence. The marked excess in deaths from this cause nullifies, to a large extent, any comparisons pos- sible for deaths from other causes, as for instance, tuberculosis. III. The tendencies in death rates for the chief causes of death, ob- tained by comparing the years 1916-1918 with the total period 1912- 1918, were found to be as follows: deaths are increasing from tubercu- losis (106.5 ^•^- 994)) cancer (45.4 vs. 41.4), cerebro-spinal diseases (70.0 vs. 57.5), circulatory diseases (90.3 vs. 80.3), pneumonia (118.5 vs. 98.1), cirrhosis of the liver (22.1 vs. 17.6), genito-urinary (non- venereal) diseases (61.0 vs. 50.5), and violence (404.6 vs. 398.2). Deaths from the following show a decreasing tendency: "other" res- piratory diseases (26.9 vs. 42.6) and suicide (29.3 vs. 31.9). IV. Malaria and typhoid fever were limited practically to southern counties where sanitary conditions, particularly water supplies and sew- 373 age disposal, are notoriously bad. All the remaining causes of death were fairly evenly distributed in proportion to the number of employees in each district. V. The age groups in which certain causes of death are emphasized are as follows : 1. Tuberculosis shows its main emphasis in the age group 25 to 34, with a gradual decline thereafter throughout the balance of the age periods. 2. Pneumonia shows a gradual increase with age, up to the age period 45 to 54, then a gradual decline. 3. The figures for other respiratory diseases are too small for de- ductions, but in general show most emphasis later in life. 4. Cancer and cerebro-spinal diseases both show a marked increase in the ^ge period. 35 to 44, then a more gradual increase to the age 64, after which there is a decline. 5. Circulatory diseases are emphasized from 46 years of age and over. 6. For cirrhosis of the liver the figures are too limited for specula- tion although the majority of deaths occur in the age periods between 35 and 64. 7. The non-venereal genito-urinary afflictions, principally Bright's disease, show a gradual increase by age period up to and including the age period 55 to 64. The figures for suicide and violence were not obtained by age periods. "All other diseases" have a very even distribution throughout the age periods, there being emphasis on the period 25 to 34 and less emphasis in the period 55 to 64. VI. The death rates of Illinois coal miners when compared with those of the entire United States registration area,® notwithstanding the number of deaths from violence, are excessive for the following afflic- tions: typhoid fever, 30.8 vs. 13.3; cirrhosis of the liver, 17.6 vs. 12.3; suicide, 31.9 vs. 14.2; and violence, 398.2 vs. 90.9.' A clearer idea of the relative importance of certain causes of death may be obtained by the elimination of violence as a factor and the com- parison of purely medical causes, including suicide. As compared with "miners and quarrymen" in general, Illinois coal miners rank : ( i ) about the same with respect to tuberculosis and cerebro-spinal diseases; (2) more favorable with respect to circulatory diseases and "other" re- spiratory diseases; and (3) less favorable with respect to typhoid fever, cancer, pneumonia, cirrhosis of the liver, genito-urinary (non- venereal) diseases and suicide. As compared with "occupied males" in general, Illinois coal miners rank (i) about the same with respect to cancer and 374 cirrhosis of the Hver; (2) more favorable with respect to tuberculosis, cerebro-spinal diseases, circulatory diseases, "other" respiratory diseases and genito-urinary (non-venereal) diseases; and (3) much less favor- able with respect to typhoid fever, pneumonia and suicide. It is hardly more than speculation to attempt to designate a cause for the increase in mortality among Illinois coal miners. Violence as a cause of death has not increased materially. Working conditions are undoubtedly getting better from year to year. Unquestionably, the in- crease cannot be charged to any single factor, such as alcoholism which has been on the decrease throughout the period covered in the figures; or fatigue which has decreasd with the reduction of work hours, the in- creased use of blasting powder and machinery; or geographical distribu- tion which has not entered as a factor in causation except in the case of certain diseases sUch as typhoid and malaria. The industry is not, in its present dimensions, more than a genera- tion old in Illinois (the same may be said for Ohio) and it is probable that more men are reaching the later age periods when deaths are more frequent. It is probable also that a greater congestion of population and its attendant evils, without a corresponding increase in health super- vision of housing and living conditions are potent and basic factors. HOW MINERS COPE WITH SICKNESS AND DEATH HAZARDS. In many industries the management takes a leading part in organiz- ing medical care, such as sick and benevolent associations; however, this is not the case in the Ohio mining industry. Any organization of the kind is supervised by the workers themselves, and its presence depends very largely upon: (i) the size of the working force; (2) the location of the mine in respect to towns and cities; (3) the racial alignment; and (4) the interest manifested by the local union which, in turn, de- pends largely upon the views of the officials of the same. If only a few men are employed, the existence of a benevolent association is rendered out of the question; if the mine is located in a populous community, many of the workers belong to secret lodges carrying sick benefits and there is serious interference with a benevolent association. Where a majority of the workers are foreigners, strictly benevolent associations have a hard time existing, inasmuch as most of the foreigners prefer to belong to their own lodges, most of which carry sick benefits and are more or less religious in character. Where a benevolent association does exist, it is invariably opitional with the men whether they belong or not, so that a considerable percentage of all workers are not members of the local union's sick benefit association. Reports were frequent that sick benefit associations maintained by the locals were decreasing in number, especially since the state compen- 375 sation act becaane operative and took over the accident features. Occa- sionally malingering was said to have been the chief cause for the break- ing up of the association. It was stated that the optional membership clause is a main reason for the ineffectual character of these local benefit societies. It was found that the national fraternal secret sick benefit associa- tions were well represented in the mining districts; and no particular one was universally strong among the miners. At one place it was the "Odd Fellows" who predominated; at another, the "Red Men" or the "Moose", etc. The percentage of miners carrying sick benefits in such associations could not be accurately obtained in this inquiry, but many whose opinions were asked put it in the neighborhood of 50 per cent. Aside from these English-speaking fraternals are the associations among the foreigners. It was the concensus of opinion that practically all foreigners belonged to some one or two or more of these orders ; and indeed, they seem more appreciative of such insurance protection than the native Americans. Many of them had already received their initia- tion into community insurance schemes abroad in the various countries from which they or their parents came. The usual forms of industrial insurance were everywhere present in the mining districts through which children, in particular, are covered for funeral benefits. Many of the miners, perhaps the foreigners more than the others, carried sickness insurance in several organizations, so that the statement was frequently made that a man while sick might draw more money in sick benefits collected than he earned while well and at work. Taking up a collection by passing around a paper or by "passing the hat" was a frequent procedure to help out some sick or injured worker. The amount of the collection usually depended on the case and too often on the popularity of the worker.' The great benefits derived from state compensation for injuries were everywhere evident. The death benefit (really burial fund) is provided by most union locals in contrast to the lack of provision for sickness. On the death of a miner, the local, by special assessment or check off at the mine, raises a fund varying in localities from $25.00 to $200.00. Usually a ' A home visited in company with a mining physician near Glouster was an instance in point: a miner, 21 years old, had been laid up 20 weeks with, a compound fracture of the foot. He was about ready to go to work again. During this time he had received state compensation and in addition two collection from among the men at the mine where he worked. These netted him $28.30 and $26.10. In the same house with him was his father-in-law, 60 years of age, who had raised 12 children, an old miner, had mined all his life until "rheumatism" had compelled him to give up at the age of 55 years since which time he has had no income 376 similar amount is raised for the death of a miner's wife or other de- pendent adult, and a graded amount for children based on the age of the child. At many large mines the company also contributes $25.00, provided the mine works on the day of the funeral. This is arranged by agreeing that only the immediate friends of the deceased attend the funeral and that the balance work. One company was said to contribute $50.00 to a funeral and another, to pay the entire funeral expense (prob- ably meaning in the case of accidental death in the mine). Unlike Illi- nois, the state organization of miners in Ohio maintains no death claim insurance department. COMMUNITY MEDICAL FACILITIES. Medical Facilities at the Mines. By state law, all mines of certain size are required to have at least a minor first aid equipment, consisting of litter, blankets, kit of bandages, simple instruments, antiseptics, etc. In Illinois, all mine managers (mine bosses) and, as a rule mine examiners, are required to have first aid training for which they receive a license. No such requirements prevail in Ohio. ' One or two mines visited had first aid teams. An emergency hospital room and ambulances were found at mines connected with large steel companies. "Safety First" was thoroughly emphasized in most mines. A refuge room or space is located near the foot of the hoisting shaft. Manholes or refuge places on haulage roads occur every 60 feet and must be on the side opposite the trolley wire on motor haulage roads. Men hurt or taken suddenly ill in the mine are rushed to the surface, — usually to the engine room, the wash house or the mine ofifice. In the mean time the physician who is called by telephone has usually arrived. After first aid attention, the afflicted man is taken home under the super- vision of the physician of his choice. At no mines did physical examinations of applicants for work ob- tain. Both workers and employers, however, commended the advisabil- ity of this. In the presence of an epidemic the mining company and the local union follow the policy of non-interference, leaving it quite entirely to the supervision of whatever local health authority is at hand. Insistence on vaccination against smallpox has been attempted at some mines. Closing of the wash house may also be ordered. The fury of the present epidemic of influenza in mining districts has been out of all proportion to other districts in the state and attests the inadequacy of health super- vision. Medical Practice. Inquiry showed that physicians in mining districts are likely to locate permanently, just as in other localities. Apparently, there is less oppor- 377 tunity for vacation periods than elsewhere. The physicians are prac- tically all native Americans. Contract practice for so much per-man-per-month or per-family-per- month is looked upon with disfavor by county medical societies and also by locals. Of the 23 physicians interviewed, two maintained a contract practice. This was on the basis of $1.50 per month per family, or 75 cents for a single man. The plan was heard of in several communities not visited. A number of physicians said they had discontinued contract practice because it was not feasible or was unsatisfactory. Contract prac- tice was formerly much more extensive in mining districts. The rates charged miners were the same as for other inhabitants in each district. The usual fees were: for calls at the house, $1.50 (before the war, $1.00); night calls, $2.00 and up; office calls, $1.00 and up, usually with medicine included; mileage, 50 cents a mile after the first mile, or, certain rates to a certain place; confinement cases, from $10.00 up, usually $15.00. These rates are lower than for the state at large; also lower than for, mining districts in Illinois. Remuneration was quite invariably upon the merit basis, — so much for so much service rendered. Physicians in mining communities are kept fairly busy with injury cases under the compensation law." A majority of the physicians, while admitting that their income is much better than before the installation of the system when they used to deal directly with the injured worker or with some private insurance company, are ruffled at the delays in pay- ment and the haggling over the question of the amount of fees, occas- ioned by their dealings with the Claims Department of the Industrial Commission. This delay is frequently due to a lack of specific informa- tion furnished by the physicians and the State Medical Society has of- fered a means of practically solving these disputes by the appointment of a complaint committee at Columbus to work in conjunction with the department. The mining physician covers a radius of about five miles in his prac- tice. Variations depend upon the directions of railroad lines and other local features. The ratio of physicians to population was tabulated and show that, as a rule, the average mining community in Ohio is sorely in need of more physicians. Most of these communities are so inaccessible that they do not have the advantage of calling upon the physicians in the neighboring cities for extra medical service. In ten mining towns in- vestigated in eight different districts, there was an average ratio of one physician to 2,016 of the estimated population. This was not due to the fact that physicians had withdrawn for army service, because very few left mining communities for that service. The ratio of physicians to population throughout the United States is one physician to 739 of the population (estimated in August, 1918). The situation in Ohio differs 378 that there was no dearth of medical practitioners in mining communities, at least in view of the present demands for their services. Except in the larger mining cities there was almost an entire ab- sence of osteopaths, chiropractors, neuropaths, optometrists, mental and faith healers, etc. Licensed midwives were practically absent. Women practicing midwifery unlicensed, especially in foreign communities, were mentioned here and there. However, foreigners were invariably de- sirous of getting a "good doctor" on such occasions. With some in- struction, many of these women could be trained to be of great practical service to the busy mining physician, although but few could meet the educational requirements of the law for a licensed midwife. The trained nurse is almost an unknown person in practically all mining communities, even in normal times. Whole counties were re- ported as without the services of a trained nurse, public or private. The number of practical nurses was found to be very limited also, but most physicians explained that there were two or three "handy" women in the vicinity to help out. Many persons expressed the opinion that a com- munity organization to assume part or all the cost of a trained nurse's services would be advisable. While an X-ray was most apt to be readily available, still, for such a convenience, as well as for most laboratory work, recourse was usually had to large cities. Such methods were reasonably prompt, but some physicians said that the practice of medicine would be much more scien- tific if diagnostic facilities were more convenient. There is just as much empirical medical practice, if not more, in mining communities than elsewhere. Hospitals The proximity and availability of hospitals to mining communities varied greatly. The accessibility of a hospital means much more to the physician and the patient's family and friends than it does to the pa- tient, who may be transmitted easily enough 50 miles or more to a hos- pital. Physicians can afford neither the time nor the expense of trips to distant hospitals; consequently, when hospitals are established in the mining community, the miners and their families use them much more frequently than when they are at a distance, and much of the physician's time is saved. It was found that miners rarely resort to hospitals for sickness, and members of their families even less frequently. The for- eigner seems to appreciate the advantages of -hospital treatment more than does the American. There is a great dearth of hospital facilities in Ohio mining districts. Cooperative hospital service existed between miners in the Glouster and Jacksonville regions and the hospital at Logan, by which miners paid $1.00 per month and received hospital services free. For some reason which was not clear, the arrangement did not appear to meet the appro- 379 bation of all of the physicians in the communities and no reply was re- ceived either to an inquiry sent to the management of the hospital or addressed to one of the officials of the miners' organization for that vicinity. . Organized Aid and the Physician The effects of the sick benefit association in relation to the phy- sician are worthy of commeilt. Members of these associations, as well as of lodges and fraternals furnishing sick benefits, usually expect most of the fee for medical services to be met by the weekly cash benefits. In order to enable the afflicted one to secure this benefit, the physician fills out a certificate of illness. These financial transactions were commented upon as often uninviting. When a miner belongs to several lodges or societies, he presents several certificates, usually each week. Some- times health insurance companies and some of the fraternal societies re- quire extensive blanks to be filled out. In practically all cases, phy- sicians stated they made no charge for this service; that they dicl the service because the patient was a regular patient and that they could not do otherwise. A couple of physicians stated that they charged from 50 cents to $1.00 for such service. Nearly all physicians interviewed com- plained that the multiplicity of certificates to be filled out gratis was the "bane of their existence." Two physicians in partnership in a busy min- ing community in Illinois stated that between them at least eight hours per week were spent in filling out sick benefit cei-tificates. Many physicians commented also upon the evident attempts at ma- lingering which were associated with collections from benefit societies, and particularly where a workman was over-insured by carrying policies in several societies. Most physicians stated that they would like to see some other system adopted for the present sickness insurance relation- ship, — for instance, the submission of bills directly to the benefit so- ciety and the dealing with a limited number of societies per patient. No one, however, attempted to devise a workable plan. The physician feels safer about his own remuneration when he is dealing with an organized body, such as a lodge or society, than when he is dealing directly with many of the patients who seek his services in mining communities. Economics of Medical Practice. There was no evidence to the effect that miners were not as good pay as any other class, considering race, locality, and status. Gen- eral average of collections was about 75 per cent in normal times, and only somewhat better at present. Some physicians reported as low as 50 per cent, but stated that they were not good collectors. Others who had more business system claimed collections as high as 90 to 95 per cent. Collections were better in isolated localities, as a rule. Increased labor 38o many comtnunities it was stated that slow pay was a bad feature, and particularly so in normal times when the mines were idle for a number of weeks or months each year. Accident compensation has resulted in better collections and more prompt demand for the physicians', services in the case of treatments for injuries. Multi-treatments, or the practice of calling one physician after another, or perhaps having two or more at the same time, each unknown to the other, was mentioned as frequent ^ in communities of foreigners. All physicians had some charity patients, the number increasing in hard times. Chronic invalidism from sickness was not above the average. Many maimed individuals are to be seen in all large mining towns. Physicians emphasized the unlimited, extent to which quackery and the practice of charlatans prevailed. Here and there counter prescribing in which the druggist prescribed something instead of sending the af- flicted one to a physician was mentioned. Also the fact that physicians' prescriptions were filled repeatedly without the physician's sanction, and perhaps for different sick persons. One physician in an Ohio town stated that a prescription of a cousin of his, a physician who had been dead for twelve years, had become the general property of the neighborhood and that whenever persons had something resembling this form of sickness, they went to a particular drug store and asked to have Dr. So-and-So's prescription No. such-and-such filled for them. The old time street medicine vender has quite disappeared from most of the mining districts of the state. However, the practice of self-diagnosis has undoubtedly extended and unquestionably increases the spread of communicable diseases and the incidence and severity of all afflictions. It is especially fostered in mining districts by various types of nostrum propaganda in which full use is made of the advertising columns of newspapers, billboards, public places and the mails. Its chief cause is unquestionably lack of ready funds with which to pay for legitimate treatment and the desire to try a substitute first because less expensive. GENERAL SUMMARY By means of a direct field survey, in which 43 mines and their associated communities in 11 of the 12 districts of the state were visited, and by means of questionnaires and conferences, the status of the health of Ohio coal miners was investigated during the summer of 1918. Soft coal only is mined. The coal mining industry in the state is steadily in- creasing, employs 50,000 workmen and the quantity of coal in sight is sufficient to last for centuries. Working conditions in Ohio mines are not as good as the average when compared with most industries in Ohio. While ventilation is good in the main, many of the mines are of a damp, muddy type and work is such tbat exposure to this hazard is considerable. Furthermore, the 38i blasting down of coal which is permitted almost universally during the work hours and which fills the mine air with the poisonous gases due to blasting powder, occasions a decided health hazard. The mining laws and regulations need amendment in this respect and the department is sorely in need of an increased force to carry out the requirements of the law. Working conditions in Illinois mines are much superior on the average to those in Ohio. Wash houses and places in which to change clothes are few and far between at Ohio mines. A glaring omission is absence of latrines for outside workers at most mines. A serious common fault is the poor character of the water supply which miners use. The eight-hour day prevails. There is practically no overtime even in the present stress. All coal miners belong (except in one mine, where wages and con- ditions are the same as elsewhere) to the United Mine Workers of America. Foreigners, principally eastern Europeans and Italians, pre- dominate. But 3.3 per cent of 4,793 employees in 34 mines visited were found to be over 60 years of age. Wages are good but, in normal times many mines are idle for weeks and months each year because of lack of demand for coal. Disastrous strikes have also caused great suffering. A damp atmosphere, with mud and water about the feet, may be said to be one of the chief hazards for the Ohio coal miner; just as important is the breathing of dust by the workers at the face of the mine, particularly about the mining machines. Physical strain, much of which could be avoided if men were selected for their jobs by physical examination at the time of their employment or after recuperation from sickness, causes a train of afflictions incapacitating in character. Housing conditions and bad forms of recreational hygiene, espec- ially alcoholism, undoubtedly constitute the major causes of most sick- ness. This whole situation is due largely to the inadequacy of com- munity health organization and prophylactic measures against disease. "Rheumatism," asthmatic afflictions and alcoholism constitute the chief forms of sickness. With the exception of tuberculosis, venereal diseases and possibly pneumonia, all common afflictions are of usual fre- quency among miners. Several diseases supposedly of industrial char- acter a,mong miners, such as hookworm, nystagmus and lockjaw, were found to be non-existent. Mortality statistics for miners are not compiled for Ohio but the information from Illinois shows that the annual death rate has been gradually increasing from the fiscal year 1912, when it was 1,003 P^r 100,000 employed, to the year 1918, when, for the first six months, it was 1,185. The cause for the increasing death rate is not clear. About two-fifths of all deaths among miners are due to external causes (vio- lence and mishaps) and consequently the seriousness of a high sickness 3^2 to the death rate in general, the death rate among lUinois coal miners was excessive from typhoid fever, cirrhosis of the liver, suicide and vio- lence. After excluding violence, pneumonia becomes a prominent addi- tion to the group, while tuberculosis approximates the average in the general population. Miners as a body or as groups, cope with the hazards of sickness and death in many different ways, none very efficient. All sorts of schemes exist depending upon locality, race, size of mining district, etc. Many miners' local unions maintain optional sick benefit societies, but all manner of modes of procedure exist. Most of them are on the de- cline because of compensation for accidents. Establishment funds do not exist in the coal mining industry. The miners' state organization does not pay death claims as in Illinois. Practically all the locals pay death benefits, ranging from $25 to $200, often times including depend- ent adults in the miner's family as well as children. The taking of col- lections and "passing the hat" are the fcommon procedure in case of sick- ness. The various' national fraternal insurance societies have strong representation in mining districts. Miners often belong to several or- ganizations and may derive over-insurance therefrom. No operating company takes a direct interest in benefit societies as in some other in- dustries. No insurance companies provide group insurance covering sickness for the employees of a mine. Industrial insurance by private companies, providing a small burial fund for children, is extensive. Community medical facilities are no more than fair. Physical ex- aminations of new applicants for work do not obtain. First aid pro- visions at mines are fair. Hospital facilities are very scarce. Local health administration is very bad. Prophylaxis and preventive medicine are hardly known in most districts. There is great need of instruction in the fundamentals of personal hygiene. Most dissipations were found to be the result of a misconception of what constitutes recreation. Medical practice in mining centers is maintained by a set of steady, hard working native American physicians, few of whom engage in con- tract practice. Fees charged miners are the same as those charged other members in the community. These rates do not vary much from one end of the coal field to the other, and, are lower than in the rest of the state. In general, there is a shortage of physicians in mining districts which at times becomes acute because of the inaccessibility of the coni- munity. Trained and practical nurses are almost unknown persons in mining districts. Diagnostic facilities are meager and most laboratory work is sent to the larger cities. If laboratory and hospital facilities were at hand, more scientific medicine could be practiced in these dis- tricts. The existing relationship with insured persons is not satisfactory to the physician. The sickness must be certified before cash benefits will be paid and before the physician may receive his fee; however, the mul- 383 tiplicity of certificates is irritating. Malingering is a considerable fea- ture. Many physicians believe that the submission of bills directly to the lodge or society of which the patient is a member instead of to the patient, might improve the situation; and that the number of societies in which a workman may insure for health should be limited. In normal times miners do not work steadily throughout the year in most districts, so that physicians have periods of decreased collections, although the miner pays as well as any other industrial class. Nostrum and quackery propaganda flourishes in mining districts, but there are very few non-medical practitioners belonging to the various cults. There is much room for improvement. It involves education in ideals to a great extent. Some organized, corrective efforts are un- doubtedly advisable. Stress should certainly be laid on the application of means to prevent sickness as well as the extension of means to cope with the sickness which exists. Suggestions for Improving Health Conditions in Coal Mining Districts in Ohio. I. The State Department of Health should be made advisory to the State Department of Mines in all matters pertaining to the health of coal miners while at work. II. The many existing schemes of health insurance which now pre- vail among coal miners should be standardized. III. All employees should be required to carry health (sickness) in- surance providing both cash benefits and medical care. Standards should be set for this. Optional membership, which characterizes the existing forms of this type of insurance, is a chief fault of the present system and should be corrected by making such insurance a condition of employment. %- IV. A plan should be devised for the extension of the trained nurse's services, physician's services and of various social services — in- cluding all that is meant in the term "Americanization" — into these districts. V. Some standard form of hospital and dispensary service should be adopted for the districts. VI. Improved diagnostic facilities, conveniences and arrangements are needed in many districts. The plans should be placed under the State Department of Health. VII. Physical examinations should be instituted as a requirement for employees at the time of their application for work and, with cer- tain modifications, after returning from an absence due to sickness or injury. It is suggested that this be undertaken in connection with state employment agencies. VIII. The financial aspects of any health insurance scheme should 384 be localized so far as possible so that the expense of maintenance may be a special consideration for the local carrier. The state may lay down minimum standards. IX. Free choice of physicians should be allowed, but each local car- rier should have a medical officer to approve bills and forms of service in general. He should be a member of a special medical committee, ap- pointed to consider all matters of contention, both treatment and cost, between the sick individual, the attending physician and the carrier. X. Routine medical services should be fee-scheduled. This is done a't present by some county medical societies. Services for complications, unusual conditions and types of cases, etc., should be compensated on a strictly merit basis having regard to some general designated standards. Plans should be made to ehcourage concentration on the given case dur- ing the early stages, irrespective of the number of calls or the amount of work necessary to establish a quick and satisfactory diagnosis and to get the afHiction under control. XL Arrangements should be made for the services of specialists and experts, both for business management of local or district carriers as well as for treatment services. XII. A certain part of all funds collected should be definitely set aside for the application of sanitary science and the prevention or re- duction in incidence of diseases of all types. The State Department of Health should have general supervision over all work of this nature. Xlll: As a clieck "against unscientific methods of treatment, all per- sons and services should be licensed and such licenses renewed or dis- approved at stated intervals by a board appointed for such purposes and equipped with such powers. APPENDIX E OLD AGE PENSIONS IN THE BRITISH EMPIRE W. B. Weidler UNITED KINGDOM The enactment of the old age pensions act, on August i, 1908, to go into effect January i, 1909, marks the culmination of a movement which began some thirty years before with the publication of a scheme drawn up by the Rev. W. L. Blackley, Honorable Canon of West- minster, proposing the compulsory insurance of all persons, with sick pay and superannuation allowances after the age of 70 years. A select (parliamentary) committee on national provident insurance, 1885-87, investigated this scheme among others and reported against their adop- tion. Since then five public commissions or committees have studied the subject of old age pensions, and have published reports.^ Two plans in particular, besides Canon Blackley's scheme of com- pulsory assisted insurance, have engaged the attention of investigating commissions, i. e. Mr. Joseph Chamberlain's plan of voluntary assisted insurance and Mr. Charles Booth's scheme of universal, non-contributory pensions. Neither of these proposals, however, found any considerable favor with investigating commissions. The select committee on aged and deserving poor, 1899, formulated a plan essentially different from any previously reported schemes. This committee concluded that old age pensions ought to be restricted to the deserving poor and accordingly proposed a plan of limited non- contributory pensions. This plan as worked over and modified by two later committees, was finally submitted to Parliament as the government measure of 1908. The plan as finally amended and adopted is partial, voluntary and non-contributory. The old age pension act provides for the payment of weekly pensions, not to exceed 5.?. ($1.22), to persons over 70 years of age, except wastrels, lunatics, paupers and criminals, whose in- comes from all sources do not exceed £31, los. ($153.28) per year. 'See Report of Royal Commission on the Aged Poor, 1893-95, Lord Aber- dare, chairman; Report of Committee on Old Age Pensions, 1896-98, Lord Roths- child, chairman; Report of Select Committee on Aged Deserving Poor, 1899, Mr. Henry Chaplin, chairman; Report of Departmental Committee on Aged n-«..*««;.«« D^«.- 1Q00_1Qn^ Qii- TT 'Wat-nilfAn ^lioirman • J?j>hnrt ni Selert Cnnu- 386 Mr. Charles Booth's scheme of universal pensions was rejected because of the enormous expense involved and because it seem_ed absurd to offer pensions to well-to-do persons who had absolutely no need of such aid. Moreover, the indiscriminate grant of pensions to paupers and workers was thought to be dangerous, as likely to discourage thrift. The idea of compulsion was abandoned both because of the difficulties m the way of its practical application, and on account of the antipathy to compulsion on the part of the English working people. The con- tributory or insurance principle was given up partly because of the administrative difficulties involved and partly because it was felt that the working class would really contribute to the funds from which the pensions were paid in the form of taxation and service in the industrial army. The statutory conditions for the receipt of an old age pension are : I. The applicant must have attained the age of 70. II. He must satisfy the pension authorities that for the last 12 of the 20 years he has been a British subject, he has had his residence in the United Kingdom. The provision relative to nationality was modified by section 3(i) of the act of 191 1 which provides that the condition as to satisfying the pension authorities that for at least twenty years previously the person has been a British subject will not be required to be fulfilled in the case of a woman who satisfies the pension authorities: (a) that she would, but for her marriage with an alien, have fulfilled the condition; and (b) that the alien is dead, or the marriage with the alien has been dissolved or annulled, or that she has for a period of not less than two years immedia'tely preceding the date of consideration of the claim, been legally separated from, or deserted by, the alien. "Residence" was defined by article 29 of the regulations under the 1908 act as mean- ing "actual presence in the United Kingdom, uninterrupted otherwise than by temporary absences." III. His yearly means, as calculated under the act, must not exceed £31, iO,f ($153-28). Aside from meeting these conditions a person is disqualified for re- ceiving or continuing to receive an old age pension for the following four reasons: (i) A person is disqualified while he is in receipt of any poor relief and until December 1910, unless Parliament otherwise determines, or if he has at any time since the first day of January, 1908, received, or thereafter received, any such relief. .\s Parliament did not take any action under the right reserved to it under section 3 (i) of the 1908 act; the principal poor relief disqualification lapsed automatically on Decem- ber 31, 1910. The act provides that the following shall not be considered as poor relief; (a) any medical or surgical assistance (including food or comforts) supplied by or on the recommendation of a medical officer; 387 (b) any relief given' to any person for the maintenance of any dependent of that person in any lunatic asylum, infirmary or hospital, or the payment of any expenses of the burial of a dependent; and (c) any relief (other than medical or surgical assistance, or relief herein before specifically exempted) which by law is expi-essly declared not to be ,a disqualification for registration as a parliamentary elector, or reason for depriving any person of any franchise, right or privilege. (2) A per- son is also disqualified if he has habitually failed to work, according to his ability, opportunity and need, for the maintenance of himself and those dependent upon him. Howevei a person shall not be disqualified if he has continuously, for 10 years up to attaining the age of 60, by means of payments to friendly, provident, or other societies, or trade unions, or other approved steps, made such provisions against old age, sickness, infirmity, or want or loss of employment, as may be recognized as proper provision for the purpose by regulations under the act. (3) Persons are disqualified while confinedin any lunatic asylum. (4) Persons are also disqualified during the continuance of any period of disqualification imposed in consequence of conviction for an ofifense. The act of 1908 provides that a person who has been, before the passing of the act or thereafter, convicted of any ofifense and ordered to be imprisoned with- out option of a fine,° shall be disqualified while he is in prison, and for 10 years after his release. The act of 1908 provides that a person 60 years of age or upwards, who has been convicted under the inebriate act, 1898, is not necessarily disqualified ; but the court, if it thinks fit, may order such a person to be disqualified for a period not exceeding 10 years. This section was rnodi- fied by the act of 191 1 to provide for a disqualification of six months' duration unless the court otherwise directs. The amount of the pension is 5^ ($1.22) weekly for all beneficiaries whose yearly incomes do not exceed £21 (($102.19). The pension is re- duced by one shilling ($0.24) stages for those whose incomes are above £21 ($102.19) and below £31, 10s ($153.28), and it ceases when the lat- ter limit is reached. The schedule of pension payments is as follows :' ""An amendment was made by section 4 (2) of the 1911 act, providing that where the term for which the person has been imprisoned without the option of a fine does not exceed six weeks, the period of disqualification is to be two years only. " In 1910 it was decided, in order to assist cases of distress, to make a grant to meet the cost of allowances, up to a maximum of an additional 2s., 6rf., a week to those suffering special hardship from the high price of food and other economic conditions arising from the war. (The Nezv Hazell Ann-ual and Almanac, 1917, p. 643.) 388 Rate of pension " Means of pensioner ' pe'' week Wiiere the yearly means of tiie pensioner, as calculated under this act : — Do not exceed £21 ($102.19) $1,215 Exceed £21, but do not exceed £23, 12.s., 6d. ($114.96) .972 Exceed £23, I2s., 6d., but do not exceed £26, bs., Od. (1127.73) .729 Exceed £26, 5s., Od., but do not exceed £28, 17s., 6d. ($140.50) 486 Exceed £28, 17j., 6d., but do not exceed £31, 10s., Od. ($153.28) 243 Exceed £31, lOj. . . .' No pension * Report of the Massachusetts Commission on Old Age Pensions, Annmties, and Insurance, 1910, p. OS. Attention should be directed to the very large proportion of full pensions at the amount of S.s. ($1.22) per week which on the last Friday in March 1915, aggregated 934,416 out of a total of 987,238 pensions or 94.6 per cent of the entire number. The following table shows by years, the total number of pensions of specified amounts in force on the last Friday in March for the years 1909 to 1917 inclusive. The Total Number of Pensions in Force on the last Friday in March, for the Ytars J{ to 1917 inclusive, and the Number of Pensions of Specified Amounts in Force on the last Friday in March for the Years 1909 to 1917 inclusive ° Year 7s. 6d. ($1,821) 7s. ($1.70) 6s. 6d. ($1.58) 6s. ($1.46) 5s. 6d. ($1.35) 5s. ($1.22) As. ($.97) 3.r. ($.73) 2s. ($.49) l.f. ($.243) Tot 1909 582,565 638,147 847,614 889,783 915,750 931,344 934,416 23,616 22,870 22,288 19,805 19,268 19,366 19,337 23,275 22,239 21,996 19,351 19,416 19,443 19.458 11,429 10,536 10,245 8,867 9,005 9,238 9.220 6,609 5,560 5,318 4,354 4,482 4,740 4,807 647,4 1910 699, a 1911 907,4 1W2 94a 1 1913 967 fl 1914 984 1 1915 987 S 1916 Not Available 1917 .... 511,263 26,071 19,348 19,560 7,0.01 808,435 19,098 20,940 10,420 5,644 947,7 ° "Reports of the Commissioners of Customs and Excise for the Years 1909 to 1915 inclusive," The Statesman's Year Book, 1918. For purposes of administration the act imposes duties on the post office, the pension officer, the local pension committees, the three local government boards, the board of customs and excise, the postmaster general, the treasury, the registrar of births, etc., and the public record office. It is the duty of the local pos^tmaster to furnish a form of claim, if neces- sary to assist in filling it up, and finally to pay the pension. The pension officer is the investigating officer, working on the instructions of the board of customs and excise under the regulations. The local government boards decide appeals, 389 and assist in framing the regulations. The bo^rd of customs and excise directs and organizes the work of pension officers, and is responsible to the treasury, which supplies the money, and assists in framing the regulations. The post- master general has to concur in the regulations so far as his department is con- cerned, and organizes, in conjunction with the board of customs, and excise, the actual cashing of the pension orders. The registrars furnish the pension officers with particulars of deaths of pensioners. The public record office has to supply information required in connection with proof of age.' Pension committees are appointed in every borough and urban dis- trict with a population of 20,000 or more, and in every county. Ap- pointments are made by the council for the borough, district or county. Claims for pensions can only be made by filling prescribed forms which can be obtained at any post office. Each pensioner's claim is payable only at one post office to be selected at the time the claim is made. The claimant must file his application either with the post ofiflce through which he wishes the pension to be paid for transmission to the pension office or with the pension officer directly. The pension committee of the district may direct that claims be sent to them in the first instance for transmission to the pension officer. On the receipt of the claim, it is the duty of the pension officer to proceed to investigate the statements made and to ascertain whether or not the claimant satisfies the statutory conditions for the receipt of a pension. The claim, together with the report of the pension officer, is sent to the pension committee which proceeds to act on the claim, com- municating its decision forthwith to the pension officer and to the claim- ant. Notice of the meeting for considering the claim must be given to the pension officer; he is entitled to attend the meeting and to speak, but not to vote. The committee, before rendering a decision adverse to. the claimant, is required to give the claimant an opportunity to appear before the com- mittee and to plead his case unless a previous claim has been made and disallowed within the previous four months, or unless the claim clearly discloses the fact that the statutory conditions are not fulfilled. The decision of the committee is subject to appeal to the local gov- ernment boards, of England and Wales, of Scotland and of Ireland. In the year ending March 31, 1915, 41,794 claims were rejected or pensions revoked either by committees or on appeal. This number repre- sents 26.05 per cent of the total of 160,379 claiins received during the year. The following table shows in some detail the claims received by years together with the actions on such claims. * H. J. Hoare, Old Age Pensions, pp. 147, 148. 390 Total Number of Claims Received during the Year and the Number of Claims Rejected and Pensions Revoked on Questions raised during the Year, by Years for the Years ending March 31, igog to March 31, 1915' Total number Total claims Claims rejected and' pensions re- voked on questions raised dur- ing the year by committees or on appeal Lapsed by death or withdrawn by claim- Year fecdveT -i-ted during •• ^"/l , theyeir --^^"ked Nature of disqualification ants unin- vestigated and Age Poor relief Means Other causes reported as invalid March 1909 1910 1911 1912 1913 1914 1915 837,831 173,370 '385,800 186,966 174,970 171,902 160,379 91,044 61,261 49,376 49,381 43,299 41,172 41,794 29,092 33,325 22,620 24,511 20,491 18,890 17,814 27,056 10,410 11,801 10,092 8,708 9,363 10,632 27,228 14,243 10,160 11,657 11,995 11,044 11,646 7,668 1 3,283 4,795 3,121 2,105 1,875 1,702 11,056 6,451 1 Not given 7,44& 6,006 5,419 5,082 Total . . 2,091,218 377,327 166,743 88,062 97,973 24,549 ■ ^ Reports of the Commissioners of Customs and Excise, for the years 1909 to 1915, inclusive. "The very large increase in the number of claims received in the year end- ing March 31, 1911, is to be attributed, in the main, to the lapsing of the principal poor relief disqualification on December 81, 1910. At the close of the fiscal year ending March, 1915, there vfcre 987,238 old age pensioners on the rolls of the United Kingdom. Of this number, 691,405 resided in England and Wales, 96,895 in Scotland and 198,938 in Ireland. Of the total number in receipt of pensions, 369-,398 were males and 617,840 females. These figures indicate a striking disproportion between the number of men and women pension- ers. The proportions of men and women were in 191 5, 37.4 and 62.6 per cent, respectively; but the disparity was less marked in Ireland where the proportions were 42.1 and 57.9 per cent, respectively. The following table' indicates in greater detail the distribution of old age pensioners by kingdoms and by sexes. 391 Distribution of Old Age Pensioners by Kingdoms and for the United Kingdom, by Sexes on the last Friday in March for the Years jgil to 1915 inclusive' England and Wales Scotland Ireland United Kingdom Year 1 Males /-3 Total Males Fe- males Total Males Fe- rnales Total Males Fe- males Total 1909 1910 1911 1912 1913 1914 1915 * 1 * 218,158 232,966 245,418 251,104 252,930 * * 395,715 409,558 423,228 433,531 438,475 393,700 441,489 613,873 642,524 668,646 684 ,,635 691,405 * * 30,440 31,406 32,372 32,645 32,553 * * 61,365 62,913 63,867 64,649 64,342 70,294 76,889 91,805 94,319 96,238 97,294 96,895 * 84,452 87,025 86,021 85,694 83,915 * * 117,331 118,292 117,015 116,608 115,023 183,500 180,974 201,783. 205,317 203,036 202,202 198,938 * * 333,050 351,397 363,811 369,345. 369,398 574,411 590,768 604,110 614,788 617,840 647,494 699,352 907,461 942,160 967,921 984,131 987,288 'Reports of the Commissioners of Customs and Excise, for the years 1909 to 1915, inclusive. A comparison of the number of old age pensioners on the rolls at the close of the fiscal year ending March 1915 with- the population of the United Kingdom (census figures of 191 1) discloses the fact that there were 21.83 o^^ ^?.^ pensioners per 1000 of the population. The number of old age pensioners per 1,000 of the population of England Wales was 19.17. For Scotland and Ireland the corresponding figures were 20.35 ^^^ 45-31' respectively. The very high figure for Ireland was due, in the main, to the very much higher proportion of the popu- lation of pension age. In fact, according to the census of 191 1, 6.72 per cent of the population of Ireland was of pension age, while only 3.36 per cent of the population of the United Kingdom met the age quali- fication for the receipt of a pension. The number of old age pensioners per 1,000 of the population 70 years of age and over (census figures for 1911) in 1915 shows a consid- erable variation, ranging from a minimum of 633.72 in the case of Scotland to a maximum of 647.30 in the case of Ireland. The corre- sponding figures for England and Wales and for the United Kingdom were 645.16 and 649.66 respectively. 392 The Number of Old Age Pensioners, the.Number of Old Age Pensioners per 1,000 of i Population and the Number per 1,000 of the Population 70 Years of Age and over, by Kindoms and for the United Kingdom, for the Years 1911 to 191S Inclusive^' Year Number of old age pensioners Number of old age pensioners per 1,000 population (cen- sus 1911) Number of old age per sioners per 1,000 popu- lation 70 years of age ar over (census 1911) United King- dom Eng- land and Wales Scot- land Ire- land United King- dom Eng- land and Wales Scot- land Ire- land United King- dom Eng- land and Wales Scot- land Irt lar 1911 ... 1912 ... 1913 ... 1914 ... 1915 ... 907,461 942,160 967,921 984,131 987,238 613,873 642,524 668,646 684,635 691,405 91,805 94,319 96,239 97,294 96,895 201,783 205,317 203,036 202,202 198,938 20.07 20.84 21.40 21.76 21.83 17.02 17.81 18.54 18.98 19.17 19.29 19.82 20.21 20.44 20.35 46.05 46.86 46.25 46.06 45.31 597.16 619.99 636.95 647.61 649.66 572.80 600.44 699.53 616.88 623.91629.43 638.83 636.33 645.16 633.72 683. 695. 688. 685. 674. "Reports of the Commissioners of Customs and Excise, for the years 1911 to 1916. The disbursement's in the form of old age pensions in the United Kingdom for the year ending March 31, 1917, were $59,341,921.06. To this figure must be added the expenses of the pension committees, which in 1912-13 represented .484 per cent of the disbursements in the form of pensions, and the cost of staff in the treasury, the board of customs and excise, the three local government boards, the public record office, the postmaster general's office, etc. The following table indicates the disbursements in the form of old age pensions by years for the years ending March 31, 1912 to March 31, 191 7 inclusive. Year. Disbursements " 1912 $57,000,847 41 1913 59,062,426 28 1911 60,193,874 93 1915 61,118,541 45 1916 1917 59,341,921 06 1918 " . .- (about) 87,588,000 00 ""Reports of Commissioners of Customs and Excise for the Years 1912 to 1915," The Statesman's Year Book, 1918. "Estimate of the commissioners of customs and excise. The marked in- crease in disbursements, as indicated in the estimate given, is to be attributed to the increase in the pension rates previously referred to, 393 NEW ZEALAND The act establishing an old age pension system in New Zealand was passed November i, 1898. Since its enactment the original act has been considerably modified by the amending acts of 1900, 1901, 1902, 1905, 1908, 1909, 1910, 191 1, 1913 and 1914. The present law relating to old age pensions is found in the pensions act, 1913, a con- solidation of previous enactments relating to old age, military and widows' pensions, and in the pensions amendment act of 1914. The qualifications for the old age pensions are briefly as follows :^' I. The applicant, if a male, must have ireached the age of sixty- five, or a female, must have reached the age of sixty.^* II. The applicant must have resided continuously in New Zealand for the past 25 years.^° III. The applicant must not during the past 12 years have been im- prisoned for four months or on four occasions for an offense punish- able by 12 months' imprisonment. IV. The applicant must not during the past 25 years have been imprisoned for five years for any offense. V. The applicant must not during the past 12 years have deserted his wife (or husband, as the case may be) and children. VI. The applicant must have lived a sober and reputable life during the past year. VTI. The. yearly income of the applicant, if single, must not reach i6o ($291.96) and if married £100 ($486.66). VIII. The net value of accumulated property must not be £260 ($1,265.16) or over. IX. The applicant mu.st not have deprived himself or herself of property or income to qualify for a pension. All residents of New Zealand who fulfill the necessary conditions as stated above are eligible for the old age pension, with the excep- tions of:" (i) Maoris who receive votes other than pensions out of the grant appropriated by the civil list act, 1908; (2) aliens; (3) natural- ized subjects who have not been naturalized one year; (4) Chinese or other Asiatics, whether naturalized or not, and whether British subjects by birth or not. "New, Zealand OfUcial Year-hook. 1917, p. 591. "The pension age Ihas been reduced to fifty-five for women and to sixty for men where the applicant is the parent of two or more children under four- teen years of age for the maintenance of whom he (or she) is responsible. The pension payable in such cases may be any sum up to £13 ($63.26) per annum, in addition to the ordinary pension payable. "Continuous residence is not interrupted by absences not exceeding two years. "JVew Zealand OfUcial Year-hook, 1917, p. 691. 394 The act is administered by a commissioner located in Wellington, who is responsible to the minister of pensions. For purposes of administration New Zealand is divided into 73 districts, each in charge of a registrar. In the chief centers of population the duties are per- formed by officers specially appointed for the purpose, but otherwise they are undertaken by clerks of stipendiary magistrates' courts. Each applicant for a pension must apply to the registrar of his district and fill in a claim form. The registrar proceeds at once to verify the applicant's statements, after which the form of application together with the results of the inquiry are transmitted to the nearest stipendiary magistrate who fixes a date for the personal examination of the applicant. The stipendiary magistrate communicates his decision to the com- missioner of pensions, who, if the pension is allowed, issues a pension certificate for the amount granted, without which no payment can be received. The term of a p.ension is for twelve months only and an application for renewal is required to be made each year. Payment of the pension is made in twelve monthly installments at the most convenient post ofifice. Any person who, by wilfully false statement obtains or . attempts to obtain a pension to which he is not entitled, is liable to six months' imprisonment or to a fine of £50 ($243.30), as is also any person who aids or abets such person. If a pensioner is convicted of drunkenness or of any offense punish- able by imprisonment for one month or more, or misspends, wastes or lessens his estate, the commissioner of pensions is empowered to pay the pension installments to an agent for the benefit of the pensioner, or to suspend the pension for such a period as he deems fit. The original act of 1898 provided for a pension of £18 ($87.58) per year, or 6s. iid. ($1^67) per week. This amount was, however, increased to £26 ($126.51) a year or 10 j. ($2.43) per week by the amendment of 1905. The full pension of £26 ($126.51) is reducible by: (1) £1 ($4,866) for every complete £1 of income over £34 ($165.44). (2) £1 ($4,866) for every complete £10 ($48.66) of net accumu- lated property. (3) ^i ($4,866) for evei:y year or part of a year by which the applicant is less than 65 years of age. For purposes of the act, net accumulated property is the capital value of all real and personal property owned by an applicant other 395 than life insurance policies and annuities, or other life interests in the capital sum of which the applicant has no interest beyond the income derived therefrom, less the following deductions : (i) The amount of mortgage existing on the property; (2) i340 ($1,654.44) from the home, including furniture and per- sonal efifects ; (3) £50 ($243.30) from any other personal property. The net accumulated property of a husband or wife for pension purposes is half of the total net accumulated properties of both. The income of a married applicant for pension purposes is consid- ered to be half of the joint incomes of a husband and wife. The joint incomes of a married couple must not exceed, with pension added, the sum of £100 ($486.66). Income includes free board and lodging up to £26 ($126.51) a year, but does not include: (a) sick allowances or funeral benefits paid by a friendly society; (b) relief by way of charity or gifts from relatives up to £52 ($253.02) in any one year; (c) pensions granted under the war pensions act, 1915; (d) capital expended for the benefit of the applicant or the wife or husband of the applicant; (e) property received on the intestacy, or under the will, of a deceased husband or wife. The pensions granted to inmates of charitable institutions are paid to the governing bodies of such institutions whenever the governing bodies can produce authorities signed by the local registrar. The pension, being for the personal support of the pensioner, is absolutely inalienable, whether by way of assignment, charge, execution, bankruptcy, etc. _The number of old age pensions in force March 31, 1917, was i9'697- The total payment in respect of old age pensions during the year was $2,336,799.18. The number of pensions in force at the end of each year since the institution of the system, the total amount paid during each year and the per capita -cost for the population are shown in the following table.^^ 'Afew Zealand Official Year-book, 1917, p. 695. 396 The Number of Pensions, the Total Amount Paid during Each Year and the per Capita Cost Year ending March 31 Number of pensioners Amount paid out Per capita cost 1899 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 7,443 11,285 12,405 12,776 12,481 11,926 11,770 12,582 13,257 13,569 14,396 15,320 16,020 16,649 16,509 18,050 19,352 19,804 19,697 $15,201 38 765,626 17 960,022 87 1,009,539 29 1,022,541 24 988,596 02 951,181 35 1,237,749 82 1,528,819 34 1,582,418 33 1,638,674 16 1,763,905 54 1,865,590 34 1,967,871 70 2,023,093 03 2,027,932 02 2,242,320 92 2,352,463 57 2,335,699 18 1.02 .992 1.235 1.276 1.265 1.172 1.092 1.375 1.658 1.678- 1.678 1.781 1.841 1.901 1.901 1.841 2.044 2.124 2.124 Sex and Conjugal Conditions of Pensioners on the Roll on March 31, by Years for the Years igi2 to 1915 inclusive.'^ Year Single Married Widowed Total Total male Male Female Male Female Male Female Male Female and female 1912 .. 1913 .. 1914 .. 1915 .. 1916 .. 2,405 2,276 2,221 2,159 269 275 382 373 3,824 13,821 3,892 4,004 2,448 2,687 3,340 3,889 2,807 2,544 2,571 2,598 4,896 4,906 5,604 6,329 9,036 8,641 8,684 8,761 7,613 7,868 9,366 10,591 16,649 16,509 18,050 19,352 19,804 19 697 i, 1917 "New Zealand Official Year-book, for the years 1912 to 1917, inclusive. 397 The Number of Old Age Pensioners, the Number receiving the Maximum Rate of i,z6 per Annum, the Percentage of Pensions at the Full Rate, and the Average Amount of Each Pension, by Year for the Years 1908- igiS inclusive'^" March 31, Year Number of pensioners Number receiving maximum rate of £26 Per cent of pensions at full rate Average amount of each pension 1908 13,569 14,396 15,320 16,020 16,649 16,509 18,050 19,352 19,804 19,697 10,774 11,340 11,827 13,936 14,209 14,017 14,270 14,449 79.4 78.7 77.2 86.9 85.3 84.9 79.0 ' 74.6 Not given 1909 Not given 1910 ! $118 97 1911 122 41 1912 121 73 1913 121 54 1914 120 67 1915 Not given 1916 1917 "New Zealand OfUdal Year-booh, for the years 1908 to 1915, inclusive. Age Distribution of Pensioners {exchisive of Maoris) by Years for the Years I9i£ to 1915 {.as of March 31).^ Year 60-64 , 65-69 70-74 75-79 80-84 85-80 90 and over 1912 4,263 4,091 4,250 3,971 5,127 5,121 5,119 5,476 4,194 3,960 3,918 3,914 1,789 2,023 .2,233 2,352 491 507 556 583 114 1913 119 1914 ■. 1,175 2,360 128 1915 139 ' New Zealand Official Year-book, for the years 1912 to 1915, inclusive. In October, 1916. the population of the Dominion (excluding, Maoris and residents of Cook and other Pacific Islands) was^^ 1,099,449. On March 31st of the same year the number of old age pensioners totaled-^ 19,804 or 1.8 per cent of the population. More detailed sta- tistics relating to population, number of pensioners, and the per cent which pensioners constitute of the entire population are shown in the following table. "■ New Zealand Official Year-book, 1917, p. 36. "Ibid., p. 595. 398 The. Population of the Dominion in Particular Years, the Number of Old Age Pensioners, and the per cent which such Pensioners Constitute of the Total Population Per cent which pen- Year Population "" Number of pensioners "* sioners con- stitute of the total population 1901 ■772,719 888,578 1,008,468 1,099,449 12,405 12,582 16,020 19,804 1.6 1905 1.4 1911 1.5 1916 1.8 ■-'■ ''f'New Zealand Official Year-book, 1917, p. 36. ""■ '-^Ibid, p. 595. AUSTRALIA. The act establishing invalid and old age pensions in the Common- wealth of Australia was passed June lo, 1908, and became effective July I, 1909. This act superseded the old age pension systems of the states of New South Wales, Victoria and Queensland. Victoria had had an old age pension system operative since June 18, 1901. The New South Wales system had been in operation since August, 1901, while the Queensland system had had a life of but twelve months, having been established July i, 1908, and was superseded July i, 1909. The Commonwealth old age pension act inaugurated a system which applies to the entire Commonwealth, including the states of New South Wales, Victoria, South Australia, West Australia, Queensland and Tas- mania. The primary purpose behind the establishment of the Common- wealth old age pension system can best be explained by quoting from the report of the royal commission of 1905 which states that:-'^ Many necessitous and otherwise qualified persons are unable to obtain pen- sions in New South Wales or Victoria from not having lived a sufficient number 1^ of years in either state. Many of these aged people have resided in Australia for a much longer period than the qualified time fixed by the acts of these states. The Australian old age pension act provides for pensions not to exceed^° £26 ($126.52),. at the age of 65, or in the event of permanent incapacity for work, attainment of the age of 60 years, to persons whose incomes from all sources do not exceed £52 ($253.03) per annum. The isr-. "Report of Massachusetts Commission on Old Age Pensions, Annuities and Insurance, 1910, pp. 112, 113. ""On September 31, 1916, due to the increased cost of living, the maxiinum pension was increased from $126.52 per annum to $158.14 per annum. The same act changed ithe maximum income for the receipt of a pension from $253.03 per annum to $282.23 per annum. 399 act of 1908 provides that the age at which women may receive an ol( age pension may be lowered by proclamation of the Governor-general to 60 years. Such a proclamation was made November 19, 1910. The following persons are expressly disqualified for the receip of pensions : aliens, persons who have not been naturalized for a perioi of three years next preceding the date of pension claim, Asiatics aboriginal natives of Australia, Africa, New Zealand or the islands o the Pacific." The statutory requirements for the receipt of a pension, in the cas of persons not disqualified on one of th^se grounds, are as follows :" I. The applicant must be a resident of Australia on the date 01 which he makes his claim to a pension. II. He must have resided continuously in Australia for at leas 20 years. Continuous residence is not deemed to have been interrupts by occasional absences not -exceeding in the aggregate one-tenth of th total pei-iod of residence. III. He must be of good character. IV. If the appHcant is a husband, he must not for 12 months o upwards, during five years immediately preceding that date, without jus cause, have deserted his wife, or without just cause failed to provide he with adequate means of maintenance, or neglected to maintain any o his children being under the age of 14 years; or, if a wife, must ne for 12 months during five years immediately preceding such dat( without just cause, have deserted her husband, or deserted any of he children being under 14 years of age." V. The net capital of his accumulated property, whether in or 01 of Australia, must not exceed £310 ($1508.46). VI. He must not directly or indirectly have deprived himself c property or income in order to qualify for or to obtain a pension. VII. He must not at any time within six months have been refuse a pension certificate, except for the reason that he was disqualified o account of his age, or for reasons which are not in existence at the tirr of the current application. The act provides that the amount of pension shall be "at such rai as, having regard to all the circumstances of the case, the commissionf or deputy commissioner who determines the pension claim deems reasoi able and sufficient." The maximum amount is fixed at £26 ($126.52 per annum; with the additional limitation that no pension shall be pai of such an amount as to render the pensioner's total income, inclusive c the pension, more than £52 ($253.03) per annum. Attention should! directed to the fact that payments received by way of benefit from ar registered friendly society or during illness, infirmity or old age fro "Report of the Massachusetts Commission on Old Age Pensions, Annuiti and Insurance, 1910, p. 113. 400 any trade union, provident society or other society or association, are not treated as incpme for the purposes of the Commonwealth act. In case the pensioner has accumulated property, the amount of the pension is subject to the following deductions : first, £i ($4.86) for every £10 ($48.66) by which the value of the property exceeds £50 ($243.30), except where the property includes a home in which the pensioner him- self resides, and from which he draws no income ; second, in case the property includes a home, in which the pensioner resides and from which he draws no income, £1 ($4.86) for every £10 ($48.66) by which the value of the property exceeds £100 ($486.66). In cases where both hus- band and wife are pensioners, the deductions shall be for excess over £25 ($121.65) ' ^"^d ^50 ($243.30) respectively, under the circumstances described above. The administration of the act is in the hands of a commissioner of pensions for the Commonwealth, assisted by a deputy commissioner for each state. The commissioner and the deputy commissioners have the power to summon witnesses, receive evidence on oath and to require the production of documents for the purposes of this act. Each state is divided into districts, each of which is placed in charge of a registrar, whose duties consist in receiving and investigating pension claims and in keeping such books and registers as are required in carrying out the provisions of the act. In general, an applicant for a pension submits a pension claim to the registrar of the district in which he resides. The latter makes an investigation and refers the claim, with a report of the investigation to a magistrate. The magistrate is empowered either to recommend the acceptance of the claim, to postpone action for further evidence or to recommend its adoption. The recommendation of the magistrate is en- dorsed upon the claim, which is returned to the registrar, who in turn transmits it to the deputy commissioner. The latter, or in some cases the commissioner, finally passes upon the claim, and if decision is favorable, determines the amount Of the pension and the date of com- jnencement, and issues the pension certificate. During the year ending June 30, 1916, a total of 11,485 claims for old age pensiona were examined. Of these, 10,222 or 89 per cent were granted, and 1,263 or 11 per cent were rejected. In the period July i, 191 1 to June 30, 1916 a total of 65,359 pension claims were received. Of this number 57,953 or 88.66 per cent were granted and 7,406 or 11.34 per cent were rejected. The following table shows, in greater detail, the applications for pensions, claims granted and claims rejected by years for the years 1912 to 1916 inclusive. 40I New Applications for Old Age P^ensions Received during the Year and the Action on Such Applications, for the Years iQls to 1916 inclusive" Year ending June 30 Total num- ber of new applications received Claims granted Claims rejected 1912 13,803 12,754 14,431 12,886 11,485 12,004 11,304 12,967, 11,456 10,222 1,799 1913 1,450 1914 1,464 1915 : 1,430 1916 1 1,263 Total 65,359 57,953 7,406 " Official Year-book of the Commonwealth of Australia, for the years 1912 to 1916 inclusive. Age Distribution of Old Age Pensioners Admitted during the Years 1911-12 to 1915-16 inclusive ™ Age of admission Year 90 and All 60-64 65-69 70-74 75-79 80^4 ,85-89 over Ages 1911-12 .... 4,207 4,710 1,873 817 285 76 36 12,004 1912-13 .... 3,903 4,880 1,802 825 279 100 15 11,304 1913-14 .... 4,511 4,945 2,085 969 386 95 26 12,967 1914-15 .... 4,229 4,464 1,655 725 285 92 10 11,456 1915-16 .... 4,105 3,869 1,419 562 195 57 15 10,222 " Official Year-book of the Commonwealth of Australia, for the years 1911-42 to 1915-1916 inclusive. Ages and conjugal condition of old age pensioners admitted during 1915-16^° are shown in the following table. The recorded ages of the 10,222 persons to whom pensions were granted during the year 1915-16 varied considerably, ranging from 2,035 ^t the age of 60 to one at the age of 95. Particulars for quinquennial age groups are as follows : " Official Year-book of the Commonwealth of Australia, 1916, p, 1133. K 402 Ages and Conjugal Condition of Pensioners Admitted during IQ15-16 Males Females Age at admis- To- tal sion Sin- Mar- ■ Wid- To- Sin- Mar- Wid- -To- gle ried owed tal gle ried owed tal 60-64 .... 66 177 47 290 364 1,860 1,591 : 3,815 4,105 65-69 .... 636 1,615 565 2.816 85 614 454 1.058 3,869 70-74 .... 173 433 235 841 50 206 322 578 1,419 75-79 .... 67 147 101 315 18 53 176 247 562 80-84 .... 10 31 49 90 7 13 85 105 195 85-89 .... 2 13 16 31 26 26 57 90 and 1 4 5 1 9 1 10 15 Total.. 954 2,417 1,017 4,888 ! 524 2,647 2,663 5,834 10,222 "'Official Year-book of the Commonwealth of Australia, 1916, p. 1134. Of the 91,783 persons in receipt of old age pensions on June 30, 1916, 37,832 (or 41 per cent) were males, and 53,951 (or 59 per cent) were females. Details for the years 1912 to 1916 are shown in the fol- lowing table. Sexes of Petvsioners on June so, by Years for the Years 1912 to 1916 inclusive ' Year Males Females Total Number Per cent Number Per cent 1912 34,897 36,010 37,346 38,165 37,832 44 43. 43 42 i 41 ' 44,174 46,933 50,434 52,727 53,951 56 57 57 58 59 79,071 1913 ; 82,943 87,780 90,892 1914 1915 1916 91,783 1917 93,672 ^ Official Year-hook of the Coinmonwealth of Australia, for the years 1912 to 1916 inclusive. 1 403 Persons Eligible and Those Receiving Old Age Pensions in Australia, 1916. Estimated number of per- sons eligible to receive old age pensions Number of per- sons re- ceiving old age pen- sions on June 30th, 1916 Percent- age of State Women aged 60 and over Men aged 65 and over Total pensioners to those eligible on an age basis Victoria 53., 850 54,250 16,500 16,300 5,600 6,250 152,750 37,000 42,000 15,100 10,850 4,500 4,120 118,070 - 90,850 i' 96,250 31,600 26,650 10,100 10,370 265,820 28,446 83,249 12,049 9,818 4,199 4,522 91,783 31.3 New South Wales Queensland South Australia Western Australia .... 84.5 38.1 ! 35.0 41.6 48.6 34.5 During the year 1915-16 the total cost to the Commonwealth for administering the old age and invalid pensions' department was $216,- 055.27, or about 1.5 per cent of the amount actually paid in pensions.'* Further details as to the cost of administration are to be found in the summary table on invalid and old age pensions. "* Official Year-book of -the Commonwealth of Australia, 1916, p. 1135. Invalid and Old Age Pensions — SunrnMry" Fi- nan- cial year :nded 30th June Number of Pen- sioners Old Age Inva- Tq- lid tal Amount paid in pensions" Amount paid to asylums for mainte- nance of pen- sioners Total pay- ments to pensioners and asylums Cost of adminis- tration Cost of adminis- tration per $486.66 paid to pen- sioners and asylums Average fort- nightly pension last day of finan- cial year 11 !?12 913 914 PI.5 916 917 65,492 75,502 79,071 82,943 87,780 90,892 91,783 93,672 I 65,492 7,4511 82,953 10,7681 89,834 13,739i 96,682 16,8651104,645 20,417llll," 23,4391115,222 26,7811120,453 $7 9 10: 11^ 12 30913 13 286,007 78 092,841 17 452,338 44 138,507 57 544,377 69 159,167 59 915,621 36 $754 23 12,612 67 36,287 10 64,654 54 69,272 38 134,447 58 154,889 65 $7,286,762 01 9,105,453 84 10,488,570 54 ll,2a3,162 11 12,613,650 07 13,293,615 17 14,070,511 01 ,752 44 190,961 80 203,569 60 216,648 92 228,774 99 233,655 59 216,055 27 $12 06 10 19 9 42 9 40 8 81 8 59 7 48 $4 64 4 64 '"Official Year-book of the Commonwealth of Australia, 1916, p. 1136, "Statesman's Year Book, 1918. APPENDIX F SUMMARY OF HEALTH AND SANITARY LAWS OF OHIO Esther Helen Burns Librarian, Ohio Legislative Reference Bureau ANTITOXIN Law provides for the free distribution of diphtheria antitoxin (G. C. Supp. Sees. 1239-1 1239-2). BIRTH CONTROL There are strict laws preventing the sale of drugs and instruments, and illegal operations, etc. (G. C. Sees. 13033-13035). BUILDING CODE Safety measures included in the building code of Ohio govern all buildings used for public assemblage and relate to proper sanitation covering house and public plumbing, sewerage and drainage, and very minute standardization for fireproof construction. (G. C. Supp. Sees. 12600-2 - 12600-31). The State Fire Marshal is charged with the enforcement of fire protection ; the Inspector of Workshops, with enforcing laws relating to heating and ventilation ; the Inspector of Buildings, with enforcement of laws in regard to sanitary plumbing, sewerage, etc. CHILD LABOR Law compels attendance at school up to a certain age and requires a certificate of a certain degree of education before a child may be employed. (G. C. Supp. Sees. 7763-7773). Stringent laws control the hours of labor, kind of employment and minimum age limit in the employment of minors (G. C. Supp. Sees. 12993-13017-14). CHILDBIRTH Law demands the certification of each person who desires to prac- tice midwifery in the state (G. C. Supp. Sees. 1283-1284). COLD STORAGE Law provides for the regulation and supervision of cold storage warehouses and the inspection of cold storage goods stipulating definite time limits within which certain articles of food may be kept in storage (107 O. L. IIS5-I- "55-19)- (404) 405 DAIRY PRODUCTS State Board of Health is required to establish thorough inspection of all dairies and dairy products so as to prevent the spread of disease and to avoid impurity and adulteration (G. C. Supp. Sees. 4458-4462). See also. Food Sanitation. DEAD ANIMALSj OFFAL, ETC. Regulations are strict against contamination of the air by putting putrid substances of any sort where they may become a public nuisance (G. C. Sees. 12649, 12655). DEFECTIVES Law provides for examination and segregation, of the feeble-minded (G. C. Sees. 1891-1934) ; also for those suffering from epilepsy (G. C. Sees. 2035-2051) ; and care for insane persons in suitable institutions (G. C. Sees. 1947-2034). DRAINAGE Law provides for drainage necessary to health, even at public expense for all land inside an incorporated place (G. C. Sec. 3647-1). The county commissioners are responsible for drainage necessary to health, outside of municipalities under the direction of the State Board of Health (G. C. Supp. Sees. 66o2-9a - 6602-9C) . In counties of more than 100,000 population a sanitary engineer- ing department may be established (G. C. Supp. Sec. 6602-1). DRUGS Law puts inspection for purity in the hands of the Secretary of Agriculture (G. C. Supp. Sec. 11 17-12). Law provides against misbranding (G. C. Supp. Sec. 5784). There is strict regulation of the sale. of deleterious and habit form- ing drugs (G. C. Supp. Sec. 12672; amd. 107 O. L.). FOOD SANITATION Under Industrial Commission, the law specifies that bakeries, places where meat, bread and dairy produpts are handled must be carefully regulated (G. C. Supp. Sees. 987, 990, 1012-1019). The Secretary of Agriculture must post in bakeries, confectioneries, creameries, • dairies, laboratories, hotels, etc. the sanitary code adopted by him for regulating such places (107 O. L. 12797-8). The Secretary of Agriculture shall establish standards of quality, purity and strength of foods conforming to standards of United States Department of Agriculture (107 O. L. 1 177-12, 1 177-13). The State Board of Health controls inspection of dairies, slaughter- houses, etc., and milk, meat, dairy products. Specially stringent in- 4o6 spection guards against spreading disease by milk. (G. C. Sees. 445^" 4462). GARBAGE AND SEWAGE DISPOSAL In municipalities the board of health under the council has control of the sanitary disposal of all garbage and sewage (G. C. Supp. Sees. 4463-4476). INFANT WELFARE Explicit provision is made for treatment of all cases of "inflamma- tion of the eyes of the new-born" (G. C. Sees. 1248-1 - 1248-7). NURSES, REGISTERED Examination and registration of nurses is placed in the hands of the State Medical Board (G. C. Supp. Sees. 1295-1 - 1295-20). NURSESj VISITING The medical superintendent of any county or district tubercu- losis hospital may appoint one or more instructing and visiting nurses to visit any house where there is a case of tuberculosis (G. C. Supp. Sees. 3153-1- 3153-3)- OCCUPATIONAL DISEASES Every employer shall, without cost to the employees, provide reasonably effective devices, means and methods to prevent contraction by his employees of illness or disease incident to the work or process in which such employees are engaged. (G. C. Supp. Sees. 6330-1 6330-10). OSTEOPATHY Osteopaths are required to be examined in surgery by the State Medical Board (107 O. L. Sees. 1288-1289). PLUMBING Law provides that a State Inspector of Plumbing be appointed by the State Board of Health and defines his duties (G. G. Sees. 1261-2- 1261-15; amd. 107 O. L.). POISON Law is strict against putting poisonous substances in public places, or in an enclosure belonging to another; also it regulates selling and delivery of such substances (G. C. Supp. Sees. 12663-12671), QUARANTINE State Board of Health, directing local boards, takes entire charge of the situation in ease of a statewide epidemic, establishing hospitals and even destroying infected property if necessary (G. C. Sees. 4425- 4457)- 407 SCHOOLS, MEDICAL INSPECTION Law makes the emptoyment of a school physician optional with each board. Care is enjoined when the presence of communicable disease is suspected (G. C. and G. C. Supp. Sees. 7692-7692-4). The certificate of the school physician that a child is physically fit for employment must accompany the age certificate which permits the employment of children of school age (G. C. Supp. Sec. 7766). SEWERAGE On the question of sewerage within municipality see GARBAGE AND SEWAGE DISPOSAL. The county commissioners have power to establish and control sewer districts in territory within three miles of municipal boundaries (G. C. Supp. Sees. 6602-1-6602-9). SPITTING There is no state law on spitting. Municipalities have authority to prohibit it on streets and on street cars, and most cities and villages rtave passed ordinances on the subject. STATE BOARD OF EMBALMING EXAMINERS Law provides for the examination and registration of all persons who wish 'to practice embalming in the state by the State Board of Embalming Examiners (G. C. Sees. 1335-1348; amd. 107 O. L.). STATE BOARD OF MEDICAL REGISTRATION AND EXAMINATION The so-called State Medical Board passes on applications for a cer- tificate to practice medicine and nursing in the state, establishing a com- plete system of examination and registration (G. C. Supp. Sees. 1270- 1279). Practitioners of limited branches of medicine are included under these provisions. STATE BUREAU OF VITAL STATISTICS The Secretary of State is charged with obtaining and preserving registration records of births and deaths throughout the state (G. C. and G. C. Supp. .Sees. 198-234). STATE BUREAU OF JUVENILE RESEARCH Law authorizes the provision and maintenance of a Bureau of Juvenile Research to which shall be assigned for examination and treat- ment all minors who, in the judgment of the juvenile court, require state institutional care and guardianship (G. C. Supp. Sees. 1841-1 1841-7). 4C& STATE DENTAL BOARD Examination and registration for the practice of dentistry is in the hands of the State Dental Board (G. C. Supp. Sees. 1314-1339). STATE BOARD OF PHARMACY Certification of all pharmacists eligible to practice in the state rests with the State Board of Pharmacy (G. C. Supp. Sees. 1298-1313). STATE DEPARTMENT OF HEALTH Supervision of all matters relating to the preservation of life and health in the state- is vested in the State Department of Health, especially referring to the public water supply and sewerage systems of cities and villages, and all public plumbing (G. C. Sees. 1232- 1261-15; amd. 107 O. L.). This department also has supervision over the making and vending of food (G. C. Sees. 4458-4460). See also FOOD SANITATION AND DAIRY PRODUCTS. STATE INSTITUTION FOR DEFORMED AND CRIPPLED CHILDREN The state appropriated $50,000 to establish an institution for the care and treatment of deformed and crippled children (107 O. L. — Appropriations). SWEATSHOPS Laws are in force against the so-called sweatshop system (G. C. Sees. 1020-1021). TUBERCULOSIS Law provides for establishment of state tuberculosis sanatorium (G. C. Sees. 2054-2072). Later laws provide for the establishment of county and district hospitals (107 O. L. Sees. 3141-3153-7). VENEREAL DISEASE The State Def)artment of Health has formulated stringent rules for dealing with venereal disease, including reporting. VICE Law provides for the abatement as a public nuisance of places used for purposes of prostitution, assignation, etc. (107 O. L. Sees. 6212-1 -6212-12). WATER POLLUTION There is explicit regulation against water pollution of any sort or producing stagnant water by obstructing streams and ditches (G. C. Sec. 12647; 12652-12654). 409 WATER SUPPLY "No city, village, public institution, corporation or person shall in- stall for public use" any water or sewage system or any subsidiary plant until plans have been approved by the State Board of Health (G. C. Sec. 1240). WOMEN^ EMPLOYMENT Advanced legislation safeguards employed women in health con- veniences and hours of labor (G. C. Supp. Sec. 1008; amd. 107 O. L.), workmen's compensation Law provides compensation for injuries to workmen and to de- pendents of persons killed in the course of their employment (G. C. Supp. Sees. 871-1 -87i-S3d). Increased allowance was made for medical, nurse and hospital serv- ice at the 1917 session of the Legislature (107 O. L. Sees. 1465-1489). WORKSHOP AND FACTORY INSPECTION Under the Industrial Commission, law provides for inspection in regard to safety devices on dangerous machinery, dusty trades, comply- ing with the regulations as to fire exits, etc. and all rules of sanitation (G. C. Sees. 979-1038). APPENDIX G SUMMARY OF TESTIMONY GIVEN BEFORE THE COMMISSION In order to obtain a more definite idea of the concensus of opinion among those qualified to discuss the various questions relating to public health and social insurance, certain individuals were invited to present their testimony to the Commission and later public hearings were held in Springfield, Cincinnati, Columbus, Toledo, Dayton and Cleveland to secure further evidence of public opinion. The following material sum- marizes the testimony. MARCH 26, 1918 Dr. France.s M. Hollingshead, Oliio State Department of Health, Bureau of Child Hygiene. Dr. Hollingshead discussed the necessity for an adequate local and state system of prenatal, infant, child and ma- ternity care and instruction. Dr. Hollingshead criticized the lack of such a system very severely, citing the failure of the governing authorities to recognize the vital importance of this work and telling of the srriall progress that has been made thus far. She declared the failure to be very shortsighted, because early neglect costs both the state and the individual very dearly in later years. Since a beginning has been made the work should be pushed with all possible expedition as being vital to state and nation in peace and war. The special need of maternity facilities in the country was strongly emphasized because the lack of such care and attention causes many deaths. APRIL 9, 191S Dr. a. W. Freeman, Ohio State Commissioner of Health. The first thing that strikes one is the very obvious and startling difference between a reasonably well organized and fairly efficient state health organization and the actual administration of these affairs in the state outside of the larger cities. The State Department of Health is meeting the usual and normal functions with a fair degree of efficiency. Some of the divisions are very strong, while the division of engineering is the peer of any in the country. There is, however, in Ohio practically no system of local health organization. The local health officers are labor- ers, undertakers and an occasional physician at salaries varying from $4.00 to $300.00 per annum In some cases the health officers' job is a sort of an outdoor relief proposition. The department considered not (410) 411 approving any health officers but on finding that then there would be no officers appointed, it decided to attack the system as a whole. So long as there are 2,141 health officers nothing will be done. The State Health Department is anxious to bring about a local health admin- istration sufficiently broad and comprehensive to include any necessary functions which may become part of a general health program. The state needs health insurance, the measure is a development of the future. There are two possible plans of health administration, one is the county unit, the other is a system of district inspectors. The system should be built around the public health nurse. One difficulty^ with the county plan is the large overhead expense. The district plan contemplates state supervisors in charge and 150 to 200 local health districts as adminis- trative units. In answer to questions it was asserted by Dr. Freeman that one of the worst difficulties is to find a place in which to care for sufferers from venereal diseases, because there is often no place which will receive them. APRIL 25, 1S18 Royal Meeker, United States Commissioner of Labor Statistics. Insurance is a community problem. "We are just beginning to compre- hend the true significance of insurance as a means of existence, by dis- tributing the burdens resulting from these hazards over a large mass of the population and by cutting down the occurrence of such mis- chances." Insurance first .started as a distributor of the risk but lately it has been discovered that it may ameliorate actual conditions. Casualty com.panies have succeeded in cutting down the accident rate. It means money in their pockets. Public or state insurance is a community busi- ness. The larger the body, the better distribution there will be. The risks of life are accident, illness, invalidity, old age, death, unemploy- ment and loss of property. In sickness and other social insurance the cost must be made as low as possible. The principal items of expense in private company insurance are ; the cost of writing new business, sending out solicitors, the cost of renewals and bookkeeping costs. In- surance is essentially monopolistic in character, the only sensible way is to recognize this and to eliminate competition, not necessarily under a state plan. Despite what casualty companies may say, we know a great deal about sickness rates in this country. People often look upon insur- ance as a new burden whereas it is only a new way of distributing the existing burden. Another important feature is the question of reha- bilitation. "I hope in any legislation that you may recommend ample provision will be made for rehabilitation." In answer to questions it was stated that provision for invalidity should be included in health insurance. He would also include benefits for dependents. Dr. Meeker would prefer health insurance to old age pensions and invalidity insurance. 412 MAY U, 191« H. H. S HIRER, secretary, Ohio Board of State Charities. There are 15,000 state wards in city and county infirmaries and 5,800, ciiildr en in public children's homes. The expense of children's care amounts to $607,229. There are 4,338 pensioned blind persons whose expense is $405,077. Preventable blindness is as high as 45 per cent, according to various estimates. Mothers' pensions are inadequate be- cause the tax levy is too low. In studying old age pensions and health insurance, sufficient attention is not given to the proposition that there is a percentage of feeble-mindedness running all through the public de- pendents about which there is little or no information. It will be agreed that a feeble-minded person is not a proper subject for a pension or in- surance. In a county in southeastern Ohio which was studied, 16 per cent of the inmates of institutions were feeble-minded. Of the persons in in- firmaries 47 per cent were there because of feeble-mindedness and only 35 per cent because of old age and infirmities. JUNE 18, 1918 Dr. George E. Tucker, National Industrial Conference Board. Dr. Tucker outlined the advantages of a policy for the prevention of sickness and argued that the first step to be taken should be a state wide health organization and propaganda. He cited statijstics of feeble- mindedness and venereal diseases and urged the necessity for immediate action. He did not believe that health insurance would act as a preven- tive measure, but admitted that the California accident insurance system which puts certain burdens on employers has resulted in accident pre- vention. He stated that health insurance would cost Ohio approxi- mately $50,000,000. In answer to questions he said that the state should pay for the treatment for tuberculosis and if necessary take care of the dependents as a charity during the absence of the wage-earner for treat- ment. He urged that the state spend $5,000,000 in sickness prevention, but condemned health insurance as expensive, impracticable and social- istic. AUGUST 20, 1918 Dr. S. a. Douglas, superintendent of the Ohio State Sanatorium. Dr. Douglas felt that health insurance as an anti-tuberculosis measure would be of great importance and would have definite and far-reaching results. "Sickness in this country is still looked upon as a personal mis- fortune. The social conscience has not developed sufficiently to appre- ciate that sickness is an economic calamity costing tremendously in money for which all members of the community are responsible in varying degrees and for which the community as a whole suffers and pays." 413 Dr. Rupert Blue, Surgeon General of the United States Public Health Service has urged health insurance as the next step in social legislation. The United States is the only great industrial nation without compulsory health insurance. The greatest statesmen of Europe from Bismarck to Lloyd George have believed in it as vital to national efficiency and have upheld it as a national policy. The only countries now without some form of governmental health insurance in the northern hemisphere are the United States, Canada, Italy, Portugal, Spain, Greece, Bulgaria and Turkey. Experience refutes the claim that it undermines the independent spirit of a people. The efifect of health insurance on tiiberculosis is important because tuberculosis is the factor causing greatest loss of life and incapacity and therefore the greatest economic distress. Tuberculosis, causing one death in every ten, occurs during the most productive period of life. Early detection of tuberculosis is very important to the worker, the employer and his associates for it means a better chance of recovery and the prevention of infection to others. Tuberculosis is a serious factor in cost of living because the victims are withdrawn from production. While 6,900 deaths were reported as due to tuberculosis, the actual loss is higher, because many deaths, reported as due to other causes, are in fact due to tuberculosis. Professor Irving Fisher, upon the basis of 155,000 an- nual deaths in the United States, estimated the money loss at $1,235,000,- 000 per year and the number of infected persons at not less than 1,000,000 or one per cent of population. The results of surveys show that these figures are too conservative. From two to six per cent of the men examined in the first draft were found to be suffering from tuberculosis. Persons inhaling animal, metallic or vegetable dust are more prone to tuberculosis than others. Tuberculosis causes 71 per cent of deaths among grinders, 59 per cent of deaths among toolmakers, 56 per cent among stone cutters and weavers, 50 per cent among spinners and 44 per cent among woolen workers. Often the manner in which the occupation is conducted rather than the occupation itself is respons- ible for the infection. There are only' two ways in which tuberculosis may be controlled : first to cure or arrest the infection and second to prevent the occurrence of the infection. Up to the present time anti-tuberculosis organizations and the activities of the state have been directed towards the cure. They have largely overlooked the matter of prevention. The state has come to see need for the treatment of early cases in the state sana- torium and for later cases in county and district hospitals. Meanwhile educational campaigns are being pushed. The modern theory of the treatment of tuberculosis supports the idea that many children have potential infections but that under favorable circumstances they overcome it and do not experience any ill effects unless the system is run down. Safeguarding people against the development of disease and early 414 diagnosis are most important. "The future crusade against tuberculosis will probably be directed largely, perhaps entirely, against the factors which reduce resistance. "Tuberculosis thrives under the conditions that poverty induces." "Inadequate housing facilities, insufficient or improper food, bad factory conditions, long hours, overwork, are all factors reducing personal resistance and here is the field for wide social activity. . Everything that makes for higher standards of living and for improved personal hygiene is a valuable aid against tuberculosis." Under any scheme of health insurance there must be adequate medical, surgical, nursing and dental attendance and treatment for the insured and dependent members of the family. In answer to questions Dr. Douglas stated that routine physical examinations of people generally would bring out greater numbers of those who need attention. Among the poor many would need sana- torium treatrnent. There is now no incentive to provide for the treat- ment of patients. If prevention could be complete, it would be as good a§ insurance but entire prevention is not possible. SEPTEMBER 17, 1918 Edna Noble White, professor, Department of Home Economics, Ohio State University. The problem I have been asked to discuss with you is, "The Preparation of Food and it's Relation to Health." Dietitians of today dealing with questions of dietetics no longer ad- vocate so-called "balanced rations." Definite , quantities of food may be given to animals or to hospital patients but the human animal will still select what he wishes from the materials placed before him. The important thing is to select wisely from the numerous food materials available those nutrients necessary for body welfare, and then to train the individuals to eat the variety offered. We therefore, speak of "well selected" toeals rather than of "balanced meals." The information we have regarding the effect of food on health is based upon study of certain types of diseases and upon animal experi- ments. It has been long recognized that certain diseases were affected by the types of food eaten — in diabetes for example, starchy foods are usually forbidden, and in tuberculosis large amounts of milk and eggs are usually given, etc. Of late years, however, it has come to be recognized that typical forms of disease develop if certain elements are lacking in the diet. The oldest form of such a so-called deficiency disease ascribed to this cause was scurvy. Crews of sailing ships in the old days frequently suffered severely from this disease and the recognized treatment was the feeding of fresh fruits and vegetables. This treatment is still prescribed though the cause is now questioned. The best known of the diseases now defi- nitely known to be due to the lack of a nutritional element is beri-beri, 415 widely prevalent in the Orient. It is a scourge of the rice eating peoples where the habit prevails of eating polished rice as the basic part of the diet. It may be cured by feeding rice scourings which contain the lacking element, — milk or green vegetables would serve the purpose equally well. A disease which is widely scattered among our southern states and which probably belongs to the same group is pellagra. The government hos- pital at Spartanburg, North Carolina, for pellagara patients treats the cases by dietetic means, feeding the types of food which have been lacking. Foods may be short in nutrients in various ways. First, there may not be sufficient food to supply the energy necessary for work and heat. Cattle given insufficient food develop in height but the skeleton does not develop in width. Reproductive powers are weakened also. Second, the protein necessary for building muscle tissue may not be of the proper character. Generally speaking, the proteins supplied by the - cereal grains are not of the proper types to maintain hfe and promote growth. They must, therefore, be supplemented by proteins from other sources — milk being one of the best. Animals fed on such rations are stunted in growth although not necessarily emaciated. Third, diets are frequently short in the mineral salts necessary for development ' and health. The shortage of lime salts affects the development of the skeleton. The shortage of phosphorous affects the skeletal development as well as other body tissues. Iron shortage, as a type of disease, is known as anemia. The patient in this case is given inorganic or medicinal iron which seems to act as a stimulant to the absorption of food iron. It is important that this fact be recognized so that the patient may be given the requisite supply of foods rich in iron. Fourth, the least known shortages in food nutrients are the elements known as growth-promoters. It is only in the last few years that they have been shown to exist and little is known about them. They were studied first in connection with beri- beri and it has been found that unless they are supplied in sufficient amounts, young animals will not grow and with adults diseased condi- tions develop. All this sounds rather technical and conveys the idea that normal selection of food is a very complicated problem. Abnormal conditions of health, unusual shortages of food or changed market conditions may make necessary the services of trained experts to regulate and advise regarding the food problems. Under normal conditions, however, where food prices are not unduly high and the markets afford variety, most people can be trusted to make their own selections, provided they under- stand a few basic principles. It is surely the business of the state to see that adequate instruction is provided to teach these basic principles in the public schools so that pupils may be taught how to live. It is imperative, for instance, that the girls be taught that safe milk is a necessity in the diet of 4i6 children and that the advance in price does not warrant its elimination in any case where the welfare of children is involved. The importance of including milk and green vegetables in all diets as a safety measure must be made clear to the future housewives if we expect to develop the best type of physical welfare among our people. I have said little about the importance of proper food preparation because the popular impression regarding our work is that we teach cooking methods only. We need to have a clear recognition of the fact that proper selection is of primary importance and that the prin-- ciples underlying proper preparation are the important phases to be emphasized rather than "rVle of the thumb" methods. This means that trained people are necessary just as in any other educational sub- ject and that sufficient time must be allowed" foT" the work in the cur- riculum. If educators in general had a clearer idea of the possibilities and necessities much better standards of food ^aching would result. Up to this time the work has suffered because hi the low standards tolerated in many schools. The expansion andf development of the work in the elementary schools is greatly to be desired especially in our industrial centers where the children leave schom at such an early age. Many agencies such as public health nurses and home demonstration agents will be of great assistance in furthering this movement. Since this matter is so directly connected with the welfare of the community, I hope the Commission may see fit to make some recom- mendations to promote the work. PUBLIC HEARINGS SPRINGFIELD, NOVEMBER 30, 1918 Dr. E. B. Starr, public health officer of Springfield. Proper administration will reduce the need for health insurance. The reduction ' in sickness and death rates thus far has been brought about by the "isolated or indifferent methods" now used, illustrating possibilities of a complete and adequate system. Treating the water in Springfield will cut the typhoid .rate 75 per cent. Dr. Starr favors medical inspection of schools and favors county health unit plan. Director of Schools Thomas said that under the present system for the medical inspection of schools, pupils do not have defects cor- rected. Springfield has one school nurse. Margaret Gray, school nurse. There is an individual health card for every child, begining with the second grade, recording examinations, defects and diseases during the child's eight years in the school. The family physician is consulted to ascertain whether defects have been corrected as recommended by the school physician but this part of the system has not been successful, so far, 417 J. W. KeifeRj president of the Board of Trustees of the Associated Charities. In many cases disease is primarily a matter of ignorance. People will not have teeth attended to, although free service is offered. People do not avail themselves of specialists and compulsion in some instances is necessary. Tuberculosis victims will not observe precau- tions. More public health nurses and city housekeepers who will go into homes and teach people what to do are needed. George Kelley, Board of Trustees of the Associated Charities. It is hard for nurses to convince people that they have tuberculosis. When a man is found who owes every man, it is necessary to protect him until he builds himself up again. Mrs. Altschul^ of Jezvish Charities, would make it compulsory to take care of health of school children. Dr. C. L. Minor, president, Clarke County Medical Society. Medi- cal inspection of school children should be by physicians, not by nurses. Of 6,000 school children examined in Springfield, 52 per cent had some defects. Many parents, when notified, failed to have corrections made, so that results were indifferent. Dr. Minor would compel parents to make correctioiis. Mr. Collins, superintendent, County Schools. One of the diffi- culties in health supervision of schools is the large number of country districts. It should be a county proposition. Dr. Anzinger. Medical men as full time officers should be ade- quately paid to look after school work. Dr. Patton. The health officer should be a full time official and should be paid a living wage. County health officers should be appointed by some centr.al authority. Mr. Kearney, Foos Gas Engine Works, Benefit Society. Ventila- tion in factories is bad. Raised dues from 25 to 35 cents a month to keep benefit association going. Also give entertainments to sustain the funds. Mr. Armstrong, Mr. Leffel and Mr. Anthony, representing benefit associations, described their associations. Miss Gadd, head nurse, International Harvester Company. "I •prefer to work for an organization where a man can get health insurance. If you were a visiting nurse and you went into these homes you could readily see the advantage of it." ,The company's scheme insists upon physicians. W. H. Stackhouse, manager, French and Hecht. Social insurance should proceed with considerable caution and prudence. "I don't believe any of you would contend that insurance is fundamentally a govern- mental function." Workmen's compensation laws are socialistic but are upheld because humanity outweighs paternalistic objection. Ohio's . 27 4i8 death rate compares favorably with that of other states. Sickness of 2.5 per cent of people is not large enough to justify adoption of health insurance as a state policy. Forty-one per cent of people more than 65 own their homes. In old age pensions one must consider the cost and the tremendous taxes which Ohio must pay as a result of war. On the basis of Australian figures the cost to Ohio of old age pensions will be $i3,(XX),ooo to $16,000,000 annually. Added to the cost of health insurance this would make a tremenedous burden. If health insurance is adopted it should be compulsory. There is no cure for poverty except industry and thrift. Insurance is not a remedy to lessen disease and promote health. Proper measures will begin with schools. The prevention of sickness is the "soundest idea in the world." Insure against occupational disease, not against all sickness. Under health insurance, there must be physical examinations of insured. The less efficient man of the less healthful man will be discriminated against. Under health insurance many will not get employment. Unemploy- ment insurance is opposed because of the temptation to malinger. With the railroad service, pension the costs are added to the rates. State old age pensions would not reduce labor turnover. The German system enslaved the workman. No American workman would make this sur- render. Mr. CreageEj of the International Typographical Union. Men of wealth see the problem from the angle of the preservation of wealth. Hundreds of organizations like the Typographical Union are unable to keep up a system of old age pensions. The problem of old age must be met if workers are not to be dissatisfied. Workers who now get $5.00 a week in sickness benefits think the protection should be larger. The government should be preserved but "I realize the way things are going it is going to be destroyed and possibly along the lines we would not wish and possibly it is necessary to provide remedial legislation or methods to arrest that, to cause the people to give more consideration instead of so much haste." As an abstract proposition, compulsory state insurance will obviate personal freedom. P. J. Shouvelin, manufacturer. The state need not insure the man who provides for himself. Workmen should be independent and ^ not lean on others for assistance. "I can't see where the great need ^ today is to insure against all sickness." The Commission should con- sider carefully additional burdens to be placed on manufacturers. The majority of men do not want it, neither do the majority of employers. On being asked as to whether insurance protection might make a man healthier, Mr. Shouvelin did not think so, since workmen's compensation tended to make men "more careless." P. A. Stall. Mr. Stall thought there was no great demand or emergency to require health insurance or old age pensions. He thought 419 it proper to care for health and for the young. Great majority of dependents suffer from shiftlessness or ignorance. Eighty per cent of trouble comes from ignorance. Education and propaganda are needed. C. W. Rich, Trades and Labor Assembly. Wage-earners getting more than $i,ooo in any one year may be found only rarely. It is impossible for men on such pay to lay up much. Public schools were once opposed because it was thought that the burden would be too heavy. Money for social welfare must come out of created wealth. Old age pensions and health insurance are practicable and will make for good. American workmen have a "healthy discontent" and want more than workmen of other countries. H. C. Wiseman, merchant. It is to be hoped that the 225,000 young Ohioans in military service will keep up insurance. The cost of old age insurance under private companies is so high as to be prohibitive. He does not favor health insurance or old age pensions. W. J. Meyers. A start should be made with propaganda in euu- :ating young children. The, Legislature should give local health authori- ties more power than they now have. CINCINNATI, DECEMBER 2, 1918 Dr. Otto Geier, Cincinnati Milling Machine Co. The fact that the army rejected one-third of the men eligible for military service shows the "necessity for a comprehensive health program." Most de- fects, taken in time, can be corrected. It would be easy to meet the economic loss of the war if an adequate health supervision proved a ay-product. Dr. Geier thought that the Commission's preliminary report showed that no health insurance legislation would solve the broad problem unless it provided for such a complete reorganization of health machinery as would assure "adequate preventive medicine," "improved quality of medical service," "necessary nursing service" and " necessary dentistry." The condition of a man's health is the state's most vital concern because it makes him a producer or consumer of wealth. He thought the preliminary report showed that there are sufficient hospital beds and dentists. The chief reason for the large amount oi sickness is the lack of proper state medical organization that will secure the best in medicine, dentistry and nursing. If health insurance can bring these things, the sooner Ohio has it, the more intelligent socially and economi- cally minded the state will show itself to be, no matter what the cost. Fifty per cent of the disease is preventable. The Ohio Commission deserves commendation for investigating medical features and for at- tempting to see that if health insurance is adopted the state will not be bankrupt by paying for preventable disease. If it had been proposed a few years ago to spend $5,000,000 a ^ear on a health program, the man who suggested it would have been sent 420 to Longview. Industry and the medical profession are now behind the plan. The man who really needs insurance is the man who has been sick a long time. Dr. Geier outlined a. plan by which the medical pro- fession and sanitary engineers would select health departments. He would make schools health centers.' He would organize health ma- chinery properly first, and then go on to other matters, such as com- pensation. In answer to questions, Dr. Geier said that the supervision of a man's health should be continuous and that absence from work should be immediately checked up. He agreed that it might help secure proper acceptance of treatment if a man knew that he was not. losing money while taking it, and that it might also enable the physician to get a better understanding of the case. He commended the Commission for its investigation of public institutions, jails and workhouses as disease carriers. He favored a continuation of investigation, by the General Assembly making additional appropriation. Discussing workmen's com- pensation, Dr. Geier said he had failed to note that it had reduced acci- dents through employers being concerned about their premium rates, which, he said, have gone "up, up, up" since the law went into effect. However, compensation law has brought up the whole question of accidents and employers are considering them from the humane stand- point. He thought that a health program would follow the same course and that adequate medical facilities should precede insurance. Physi- cians have not thought of dealing with masses. Any insurance plan must enlist good men and must not allow the poorest to preempt the medical field. If the medical profession should be elevated and not lowered Dr. Geier considered insurance justified, no matter what the cost. Hospital facilities and hospital treatment would be likely to increase under health insurance. For the irreducible minimum of disease some plan of insurance may be necessary, but man has a duty to keep himself well and the state has a duty to keep him well. When there is a system of real supervision with segregation of certain diseases, compensation will be of small moment. The cost will be negligible when' measured with the good. George E. Silverman, Legal Aid Society. Mr. Silverman re- viewed forms of commercial health insurance policies and experiences in adjusting claims against companies that write health insurance among the poor. Experience often is unsatisfactory. There are many loopholes through which the company may escape. There is much trouble over the policies of companies that collect on the basis of 25 cents a week. Mr. Silverman was often compelled to submit cases to the Insurance Department. Dudley Outcalt. There is debatable ground and room for dis- cussion of the insurance plan, but there can be no question on the sub- 42t ject of an immediate program for health conservation. Among 4,000,000 boys and men called into the army, disease has been reduced 80 per cent and if Ohio has any obligation, "any duty of the hour," it is to conserve the health of these men. The Commission should prepare legis- lation for an adequate and efficient health service in Ohio. The value of efficient health organizations in cities like Cincinnati is greatly reduced because five miles from the city there may be a health menace. Ohio should provide a powerful, efficient and well-financed department of health, which must be coordinated with local agencies. J. G. ScHMiDLAPP, president, Union Trust and Savings Bank. Mr. Schmidlapp told of the Schmidlapp apartments for negroes, one unit of which houses 188 families. In these families in three years there have been 16 deaths. There has not been a single death from influenza and only nine cases. All apartments have baths. There is no way of getting health insurance save by state action. He is friendly to health insurance. Figures, however, may be misleading. Various views obtain in Germany, some claiming that it is a success and others that it is a failure. In answer to questions, Mr. Schmidlapp said that health insurance depends upon housing. It is doubtful whether a man can be compelled to have his premises inspected, but it is the duty of the state to compel men owning property to have it properly sewered. This would be of benefit to the community in general. He fears old age pensions because the tendency is constantly to lower years and to increase the allowance. "If you can start at 70 and say it will be retairied there I am friendly to it." He would prefer to see old age insurance than old age pensions, because there would be less danger of lowering the age than in old age pensions. Dr. Kreidler, Cincinnati National Social Unit. Dr. Kreidler told of the Mohawk-Brighton district and said that the results were truly astonishing. In the district 36 physicians have banded together and through a committee of nine have a sort of health board which has worked out a scheme of disease prevention never before equalled in the state. Children's defects are discovered and advice is given for cor- rection. Of 1,173 school children, 1,040 were examined free and nurses have followed to see that recommendations were carried out. Prospective mothers are given free advice and babies are started in the world in a proper manner. Influenza victims are subject to inroads of tuberculosis but this has been guarded against. Only 29 cases of tuber- culosis were knowdn to exist when the unit was organized but now 112 cases are under care and control. Death rate in the district, which is a poor one, has been reduced and is now 50 per cent less than that throughout the entire city. . Best results are to be obtained by organizing the medical department. 42^ In answer to questions Dr. Kreidler stated that special cases can, through national organizations, be submitted to specialists. The organi- zation of the unit is by Hocks with 500 people to the block. Each block has a council and selects a block mother. Parents feel they are a part of the experiment. He considered the plan capable of universal expansion. Every physician in the unit has improved through the train- ing he has received. Cincinnati pays $700,000 for a great hospital but it should spend half this sum on prevention of disease. E. J. Wohlgemuth, Publisher, National Underwriter. The com- mission is making no mistake in getting away from insurance and down to prevention. If insurance is planned it will make it better. He is op- posed to paternalistic insurance, which is semi-socialistic in character. America, he said, stands for idealism and individualism and health in- surance measures are not progressive but paternalistic. He objected to Ohio workmen's compensation law because it is monopolistic and compulsory. He believed that the time would come when the law would be changed to rid it of the obnoxious feature of monopoly. In answer to a question as to whether he had any evidence to sup- port a charge that had appeared in his paper to the effect that health insurance is financed by German propaganda and German money, Mr. Wohlgemuth said it was not fair to make him responsible for all that appeared in the paper. Maurice B. Hexter. Rabbi Hexter considered that the med- ical profession is .ready for health insurance when educated up to it. In putting prevention before health insurance, the Commission may be playing into the hands of the industrial insurance companies. Prevention, insurance and medical provision must be woven together. In 191 1 there were 34 deaths from tuberculosis among Jews, in 1914 only 19 and in 1916 only 13. This was cited as proof of the ability to stamp out the trouble. He would favor periodical examinations which cannot be had without a more or less compulsory feature. The danger from malingering is over-estimated. In 1917, 76 per cent of money expended by the United Jewish Charities was for relief made necessary by illness. Health insurance should be carried through existing agencies, fraternals, labor unions, establishment funds, because it brings it nearer a man's pocketbook. If fraternal and other organizations were used, they should be actuarily examined in order to determine their solvency and to have them come up to state standards. Hospital treatment should be compulsory. Communities having an abnormally high death rate should be made to pay more. He prefers pensions to old age insurance because wages will not permit contributions on the part of labor to the other scheme. Old people cannot be satisfied in homes for aged people. Henry Ott, Central Labor Council. In regard to health insurance Mr. Ott said that if wage-earners were given sufificient wages there would 423 be no trouble. Workers can guard against all contingencies if given sufficient wages. If old age pensions are established minimum age should not be more than 65. In answer to questions, Mr. Ott said that he personally was not in favor of old age pensions, but that his labor organization is for it. He is opposed, he said, because he does not want anybody to do any- thing for him or his family. Courtney Dinwiddie, Cincinnati National Social Unit. Mr. Din- widdle favors sickness insurance of which the fundamental principle is that the man laid up with a long sickness will be helped in bearing the burden and that the cost will be distributed. Early diagnosis is one of the best steps to secure prevention. He would have expenses of the diag- nostic clinic borne by the public treasury or the insurance fund. H. R. Burnet, Public Health Council. The physician has too often been left out of schemes of health insurance in the past. Medical organization is now in complete chaos. If it is true that preventive medicine is now in the hands of 2,141 so-called health officials, village blacksmiths, carpenters, etc., unless plans contemplate other than pres- ent "health officers," it is grotesque nonsense to discuss health insurance or the extension of medical inspection to school children, children of pre-school age and infants. The county would be the ideal unit for health work under the direction of the State Department of Health. The officer in charge should be directly responsible to the state department. Health insurance could not work without an adeqliate health organiza- tion behind it. A definite effort should be made to relate practicing physicians to departments of health. The health officer should be the head of a local panel of physicians. It should be the duty of this panel to make complete physical examinations of all citizens. This should be extended at once to children of pre-school age. Children starting out to work should be certificated as to immunity from possible harmful effects of occupation. All those handling food in any way should be licensed. Health officers and physicians might be invited to the manufacturing plants to make examinations and they would be called when the advant- ages were made apparent. In answer to questions he stated that remuneration of physicians for physical examinations should come from a special tax. Henry Backus, Anti-Tuberculosis Society. Medical reorganiza- tion is absolutely necessary. A health program should be mapped out independently of health insurance. If, however, it were possible to re- duce sickness 50 per cent, the other 50 per cent would need assistance. A second step would be necessary, — health insurance based on complete health reorganization. Health facilities now are far from adequate in nurses, physicians and hospitals. If the state is to get good health officers it must pay them more. Health officers should come up to 424 standards set by the State Department of Health, selected through classi- fied civil service examination. Julian Pollak, PoUak Steel Company. Mr. Pollak stated that he v/as opposed to workmen's compensation at first, but that it has worked out admirably. "'It necessarily follows that the health insurance proposition is going to work out and be as practicable, if fully consid- ered, as the workmen's compensation has been from a manufacturer's point of view." Loss of time, absenteeism, and those things go back to ill health. Old men and old women should be taken care of. For pay- ment worker and employer should go "50-50" and the public should pay the cost of administration. B. L. HiTCHiNS, International Typographical Union. It is to be hoped that the same results that followed workmen's compensation will follow health insurance. "We spend billions to protect our property, why not millions to protect our health?" Why should those who create wealth be left to chance? Working men will object to physical exam- ination's because they already have enough to worry about with bad housing, low wages, etc. If better wages were paid, better living con- ditions would follow and there would be less need of pensions and insurance. Health insurance and old age pensions, however, put some- thing before the worker to make him feel that his future is secure. Better health protection for the people of the state is needed. If employers may inspect Workers, then workers should have the right to inspect employers to see if they are fit to employ men. In answer to questions, Mr. Hitchins stated that he feared health insurance might bar a man from work. Pensions in old age would never be regarded as charity. He proposed $5.00 a week as the sum. The medical profession should, like the teaching profession, be supported by the state. If physical examinations could be prevented from becoming an instrument of discrimination, workers would riot object to them. Dr. Robert Carrothers, surgeon. The vast majority of medical men who have to do with workmen's compensation have found that in a very decided degree it is not successful so far as medical men are concerned. Workmen's compensation does not give the men enough. If a man loses four fingers of his right hand at 30, his l6ss of earning power would be $20,000, while the state would give him $780. A physi- cian will do $300 or $400 worth of work and get $50 for it. Health insurance is un-American. Men rejected in the draft have been strong enough to do heavy work. This must be considered in discussing the health of the people. In answer to a question. Dr. Carrothers said that health insurance is not apparently satisfactory. There would be no objection to a volun- tary plan. 425 Reverend Joseph Greiner, St. Xavier's College. Health insurance is an improvement. Give the workers fair wages and paternalistic legis- lation is not necessary. Health insurance is a philanthropic measure. Anthony Mees, If there were neighborhod clinics they would be a great advantage. "When that is done, we want to bring up the industrial insurance proposition." George Eisler, American Naturalization Society. Americans make little attempt to benefit the social condition of foreigners. Many of them are exploited by physicians. Abbie Roberts, Ohio Graduate Nurses' Association. Many nurses are agreed upon the necessity for health insurance. The ill effects of prolonged illness are seen by them. H health insurance should be adopted, emphasis should be laid on nursing care. Health insurance should include dependents as well as adults. The benefits of health in- surance should be open to all. COLUMBUS, DECEMBER 4, 1918 Vernon M. Regel, assistant superintendent, Public Instruction. "No doubt there is need for health supervision in the schools." In cities there is not full realization of it as a part of the educational program. In rural districts little is provided. When people realize that every child has a right to demand from the public school system opportunities for complete development, there will be a change of ideas and attitude toward education. The child's physical welfare should be looked after. Teachers now teach hygiene and sanitation but do not make it a point to see that they do anything. Teachers do not require correct standing and sitting postures. Country people often think no supervision is needed but they are mistaken. In rural Pennsylvania instances are recorded where 94 per cent were found defective. A child cannot do good work when in poor physical condition. People are reluctant to take up correction of defects. Power should be vested in county boards of education because of the multiplicity of local boards but treatment should not be compulsory although there is need of it in some cases. Time must be taken to work matters out, as country people are conservative. R. E. Miles, Institute for Public Efficiency. "There seems to be a general recognition of the inevitability of social insurance, the only question being how soon it is coming." It recognizes that irregularity and interference with work are more serious than too low a level of income. It is an unjust condition which now obtains by which the family of the wage-earner is plunged into misery when work stops although other workers, presumably managers, superintendents, etc., may be absent without loss of compensation. It was found in New York 426 that the health supervision of children gave incomplete results because parents did not follow up the recommendations offered. Visiting nurses secured treatments in 90 per cent of the cases. It is agreed that the visiting nurse is the key to the situation. Examinations of school chil- dren should be made by physicians. There are a great many com- munities in the state with no physicians and nurses. The war has increased the need for health insurance. Emile E. WatsoNj actuary, Industrial Commission of Ohio. Under merit rating plan employers are penalized if they have an abnorrrial number of accidents. Through constant reference to experience, the Industrial Commission seeks to protect the employers against the burden of increased accidents. The prevention of accidents will decrease labor turnover which is a heavy cost. It is not possible to say off-hand whether the principle of merit rating could be applied to health insurance as it has been to workmen's compensation. However, it would seem that health insurance would have the effect of calling to the attention of employers the conditions of industry as to health. There is an increase in the number of accidents reported since the enactment of workmen's compensation, but it is notorious that accidents were not reported before enactment of this law as there was no incentive to report them. Thomas J. Duffy, chairman, Industrial Commission of Ohio. Work- men's compensation has made both employers and workers , study the subject of accidents. Employers have installed additional safety devices and many up-to-date men have conducted educational campaigns. The average employer will not install safety devices without some form of compulsion. Some employers go far beyond the law's requirements. In health insurance the contributions of the worker should be a big factor, both for the moral benefit of it and also because the worker wants no charity. Medical attention should be given, no matter what it costs. Cash benefits should continue as long as a man is incapacitated. As to. old age pensions, a system to which labor contributes is preferred. Helena C. Stewart, director. Bureau Public Health Nursing, State Department of Health. Since January i, 191 1, the number of public health nursing centers has grown from 9 to 69, employing 500 nurses. There are two tuberculosis nurses, one child welfare and one prevention of blindness nurse in the Bureau of Public Health Nursing. The bureau proposes to divide the state into districts with a nurse in charge of each. "We want at least one public health nurse employed in each city with a populaSbn of 5,000 or more and at least one nurse for each county." There should be a law to permit city councils and health boards to appropriate money to pay public health nurses. The University of Cin- cinnati and Ohio State University give training in public health nursing and assure a supply within a few years. Thirteen counties now have nurses. The work began with the Society for the Prevention of Tuber- 427 culosis. Nurses do general work, they teach hygiene and health to school children. Schools would like to have nurses go through them. How- ever, there are not enough trained nurses now for this work. It would take four or five years to find enough nurses. The services of nurses coming home from the war may be secured, but for public health nursing, special training is needed. General pay for nurses is $75 per month. People are ready for service although some do not wish to pay for it. Daniel J. Ryan, general counsel, Ohio Manufacturer^ Association. While the manufacturers have not gone into the problem as deeply as they would wish to, it is the opinion of the executive officers that at this time they deem it inopportune for financial reasons to launch a system of social insurance. It is a transitory period. Investigations should be continued further. Manufacturers are not necessarily opposed to insurance. They have been too busy with war and with trying to keep afloat. The proposition should be held in abeyance. Manufac- turers would approve a better county health organization. In answer to question, he said that he was not one of those who worry about spending too much money, adding: "I think that this is the purpose of public money — the more you spend judiciously for social protection* and social elevation, that is the way money should be spent." Ohio is lightly taxed. Mary Louise Mark, Ohio State University. "Women workers at all times are limited to a certain degree by physique." They are more susceptible to fatigue The nervous system of woman is less robust than that of man. Women in industry have to do domestic work and tend to children in addition. People are much less susceptible to poisons and illness when they are not overworked and when they are well fed. Night work is especially injurious to women, although many women in industry insist upon doing their factory work at night and domestic work in the day time. Lead and mercury poisoning is especially severe in its effects on the reproductive organs of women. Women in cotton mills are victims to tuberculosis to a greater extent than men. Many more women will enter industry in the future. Employment conditions have increased the need for social insurance so that a human scrap heap will not be created. The manufacturers' interest and the interest of society ought to be one and the same thing. Health insurance would tend to prevent illness. In Lawrence, Massachusetts, women go back to work one week after childbirth and many children have been born in the factory. A scheme of maternity insurance would keep women away from work a certain length of time. More women are found in those industries and in those factories in which the pay is low. Dr. C. p. Linhart, consulting physician to the Board of Education. Columbus has one medical inspector and six nurses in the schools. An examination by a nurse once each year qi every pupil is attempted. 428 Children in poor condition are sent to the medical examiner. Recom- mendations are made to the family physician. Eighty per cent of children have defective teeth. Hospitals give free service to those who are not able to pay for it. Follow-up work pays. Gradual im- provement can be noticed in pupils from districts over five years ago. Adequate hospital service is as necessary as police and fire department service. Emery R. Hayhurst, consultant in industrial hygiene, Ohio State Department of Health. "I am in favor of state supervised compulsory health insurance." Reasons for the statement were grouped under the three general headings. (i) Curative medical service to the average worker is in a bad way as it now exists; (2) preventive medicine, or hygiene and sani- tation is in a very bad way; (3) the object under health insurance as well as under workmen's compensation insurance is to rehabilitate the man. "Insurance actuaries state that private medical practice is from 25 to 60 years behind the status of medical science and surgical skill. The socialization of medical service must come. "Sickness is about 50 per cent more prevalent than it is judged to be." In normal times, Germany and Switzerland, although on lower wage scales, have far less destitution and want. This is claimed to be due to social insurance. In Massachusetts between $15,000,000 and $20,000,- 000 is spent annually in charity. Income of physicians is not what it should be. Under health insurance reasonable pay would be given to all who perform services for insured. Hospitals would be saved caring for charity patients. Insurance will create additional demands for physi- cian, surgeon, dentist, hospital, nurse, pharmacist and dispensary. Under health insurance people will call the physician earlier and mortality rates will be lower. "Health insurance will increase the incentive for scientific research in medicine. Germany, Austria and Switzerland have produced more scientific medical literature and delved deeper into basic science between the years 1890 ^nd 1914 (during which period these social insurance schemes were well developed) than all the rest of the countries of the world combined." Some incentive must be furnished to make man be his own health officer. Dollars will stimulate hygiene. "Make prevention and re- habilitation the cornerstone of health insurance." Preventive medicine in industry by the same token will be stimulated. Six claims for health insurance are that it will (i) relieve destitu- tion and give a better chance for recovery, (2) give the patierit neces- 429 sary rest, (3) give organized medical aid, (4) protect workman's family, (5) reduce deaths in childbirth through medical care, (6) encourage collection of facts as to sickness. Health insurance should be compulsory, says Miles M. Dawson, because it is a public matter, because there is no other way to reach all, because public will not carry voluntary insurance, because no other plan is available, because it is more economical, because insurance should follow the employee and because the state can justify its contribution on nq other basis. In answer to questions Dr. Hayhurst stated that he believed the merit basis the proper one for remunerating physicians for service under health insurance. Bills for medical services should be handled by local medical societies on the basis of number of visits. Some physicians must remain on a salary basis. There is another side to what is termed malingering. Sir John Collie's researches in England show that many of these people are not intentional frauds "and that they have a mental deficiency in their malingering tendencies which shows up under proper examination." There should be more physicians than Ohio now has, so that sickness may be better cared for. Trade unions, fra- ternal societies, establishment funds and various foreign societies might be accepted as carriers of health insurance subject to an actuarial test. . Above all local societies should handle the matter. The burden should be placed 40 per cent on employers, 40 per cent on employees, 20 per cent on the government which should pay the cost of administration. James E. Baxjman, Acting Commissioner of Health for Ohio. Mr. Baumann outlined present health organization under the laws of Ohio. There are more than 2,000 local health officers, appointed by municipal boards of health, village councils and township trustees. The State Department of Health has nothing to say from a supervisory standpoint as to the qualifications of members of health boards or of health officers. While the state department may refuse to approve appointments, it has nothing to say as to salary. There is practically nothing to do but to concur in the appointments made by councils, .^t the present time 35 per cent of the health officers are physicians ; others are from all walks of life, from ministers to retired farmers and persons without occupation. The time is at hand for changes "and we were very much gratified in the state department that Mr. Lapp and others working with him had come to that conclusion." Dr. C. A. Probst 20 years ago presented a bill for county health organization. An elective officer is not advisable for the State Department of Health should be directly assured of qualifications. The department is very much interested in medical inspection of school children, because there are very few places now where there is adequate health supervision. The department is also interested in extending the public health nursing 430 system. The very best things that can be done are health supervision of schools, the establishment of adequate local health organization and of public health nursing as preliminary to any system of health insurance. Dr. H. J. Means, medical director, Jeffrey Manufacturing Com- pany. Dr. Means disagreed with Dr. Hayhurst as to methods but agreed on the desire to improve health conditions. Health insurance would be of no avail without good physicians or good medical service. The state must provide against charlatans, quacks,- etc., or else the individual will not receive better medical attention than he receives today. Dr. Means told of the complete emergency hospital of the Jeffrey Manu- facturing Company which treats hundreds of men. Accidents are not increasing but those formerly not reported are now reported. Days of disability have been reduced 50 per cent. Prevention of infection is the secret of success. It is not clear just how it can be controlled under health insurance as outlined by Dr. Hayhurst. During the epidemic of influenza men were sent home as soon as they were found ill. Could this work have been done better under health insurance? Former Ambassador Gerard has said that social insurance in Germany was an instrument of bondage. In Germany the average number of days each worker is incapacitated is nine or 10, while in America it is eight. Health boards should be given much greater powers. County iniirmaries should be made into hospitals. American Insurance Union is for humanity. It has no business consideration in this matter of public health. Medical inspection in schools and propaganda of public health should be under- taken. In answer to questions, Dr. Means stated that unless a worker is protected, a long period of illness would reduce him to poverty. George W. Savage, secretary and treasurer. United Mine Workers of Ohio. Mr. Savage regarded Dr. Hayhurst's arguments as con- vincing. The improved conditions at Jeffrey Manufacturing Company's plant noted by Dr. Means under workmen's compensation system is strong argument for health insurance. If compensation improved con- ditions in one respect will not health insurance in another? Improve- ment in coal mining regions is sadly needed. The great step now is to pass an old age pension law. Miners are strongly in favor of old age pensions. Companies refused work in the mines before the war tO' men past 50. There is no proper health system in Ohio. "If we had health insurance, I believe the state would see to it that sanitary con- ditions would obtain and the people be taught the things they should know. If compensation law has helped to some degree, then health insurance would do it in the same degree." Miners in old age may become objects of charity and they are heartily in favor of old age pensions. 431 TOLEDO, DECEMBER S, 1918 C. A. Benedict, director, Public Welfare. Sickness prevention is the big thing. The health department in Toledo, as elsewhere, is handi- capped by lack of funds. Dr. C. W. Waggoner, Commissioner of Health, Toledo. "I feel that preventive medicine, public health and hygiene and industrial hygiene are the big factors in promoting the welfare of any community, city or country." "We know that definite outbreaks of infective diseases could be controlled if we had certain measures upon which we could rely as compulsory measures." Lack of education is the principal source of all danger'. These dangers are the insanitary condition of their homes, quality of their food, the condition of places where work is carried on as regards ventilation, dust and crowding. A large part of the popu- lation of county tuberculosis hospitals comes from homes that have bad surroundings, have no ventilation beneath the houses, or are situated in damp, boggy places with pools of water beneath. In county hospitals men and -women are found who have been employed in work places which were conducive to lowering vitality and resistance. Some of the victims of preventable diseases will be incapacitated so long as they live. If health authorities had the power of compulsion, they could go to streets and find houses with lo rooms that ought not to be in- habited at all and 40 or 50 people living in them. In enforcing regu- lations the principal trouble now is that injunctions may prevent en- forcement. The interest of the community in these conditions is that families of breadwinners may be thrown on the community when the head of the house is made ill by bad conditions. Proper public health measures, properly systematized, with full time men and women working, can give results that will astound the* community. In answer to ques- tions, Dr. Waggoner stated that he would limit the number of people to a given cubic air space, and that he would give health authorities power to segregate contagious diseases. He would also compel isolation for venereal diseases. When it is recalled that about 90 per cent are infected with one kind of venereal disease and about 40 per cent with another, it is high time that something be done. J. W. Whitmer, Superintendent of Schools, Lucas County. Medi- cal supervision is. very helpful in rural sections. Toilet facilities are bad. Anything that will give the health authorities more power and will give the schools full working time doctors and nurses in school work would be welcome. County schools have only one nurse who investigates tubercular conditions. He wotild approve compulsory inspection of school children. Children in bad health due to home surroundings have a poor chance. 432 Grace S. Frost, president, District Nurses' Association. There is need of a free dental clinic, not alone for children in the pubHe schools but for adults as well. There is also need for more accommodations in county tuberculosis hospitals so that there will be no waiting list. Open-air schools should be enlarged. Medical inspection in the schools should be extended. Children should be given a mid-day meal in school if they are suffering from malnutrition. There is need for state super- vision of private boarding homes for babies. Amy Maker, Consumers' 'League. The National Consumers' League has gone on record emphatically for health insurance and sick- ness prevention measures of all sorts. The means of studying the effect of certain occupations on health are inadequate. Malingering under health insurance is apparent, not real. People were availing themselves for the first time of early medical care and perhaps a few days rest, which had been impossible before. When it becomes a matter of dollars and cents to cut down sickness, it will be cut down, there would be proper hospital facilities. Medical inspection for children going to work should be instituted and a certificate stating that they had had a special inspection for the specific occupation they were going into should be provided. Children who are working should be followed up by inspection. Maternity insurance should be provided. Effects of occupations on women should be studied to see that future generations are not injured. Hot food at noon for workers should be accessible. Mrs. Silas E. Hurin, president, Women's Council of Defense. Working girls should have proper food at noontime. Mrs. G. C. Bittner, president, Housewives' League. Heartily in favor of old age pensions. In other countries it has done away with almshouses entirely. There is a great deal to correct in stores and mercantile establishments. Foods have been found to carry communi- cable diseases. E. J. Brown, superintendent, Lucas County Children's Home. Grown people are apt to be careless of the health of children. A conscientious physician can find many things that may be corrected while the child is young. Children in a well managed orphanage have better medical care than those in an ordinary home. While the child does not get many good things he would in his own home, in the matter of health he is better cared for in a children's home. Examinations are too superficial and provision for better medical care should be made. Rev. Father Carl J. Alter, director, Catholic Charities. There should be an examination before a child is admitted to a home for orphans in order to prevent contagion and to cure remediable defects. Among 137 children 50 necessary operations for adenoids and tonsils were performed. There -should be compulsory physical examination 433 of school children. The county ought to be the health unit. Through the county system adequate facts can be secured on which the state can base a program. Dr. W. H. Snyder, physician, formerly president State Medical Association. A strong state department of health is the greatest need. Men should be paid good salaries and should be under full time service. A compulsory health examination should be made when a child is ad- mitted to school. Some of these examinations may be made by nurses, but a good physician is to be preferred. Nurses, for example, can make eye tests but to determine whether diseased conditions obtain should be the work of a physician. Getting physicians by competitive bidding will result in poor work and poor quality of men. The number of deaths and the number of days lost by sickness that are absolutely preventable are shameful. The experience of nurses in the prevention of blindness is an example of what may be done. Juvenile judges have used per- suasion on fathers to fit their children with glasses, with good results. Great trouble, too, is in the lack of correlation between state and local boards of health. There are health officers who cannot read and write, as has been proven when physicians send them notices on cases of eye trouble in children and health officers have been unable to read the cards. It costs the state $8,000 to educate a blind child, not counting what is lost by lack of productivity. It would be good business for the state to spend money to prevent blindness. Sickness is paid for by everybody, no matter whether he is an employer or not. Business men ai^e becoming interested in health matters. Answering questions. Dr. Snyder said that sickness prevention should come before sickness insurance for it would be getting the cart before the horse in. trying to use sickness insurance as a means of preventing sickness. Prevention has not been given a fair trial. There are not enough nurses and physicians to begin the system. We must hope to train new ones. The state should try to secure men with the degree of doctor of public health. The only people who can com- mand the best medical service are the very rich and the very , poor, gradually good medical service will grow around good health organiza- tion. Physiology as it is taught today in the public schools is a lot of "rot." It is very difficult to teach hygiene and especially sex hygiene -properly or health habits. ■James J. Dunn, Associated Charities. Thirty per cent of all the poverty that has to be relieved is due to sickness. People generally do not wish medical aid furnished, preferring their own physician. A. T. Gallagher, Metropolitan Life Insurance Company., In Toledo, the Metropolitan has a working interest in 60,000 people, and ib,ooo,Ooo in the country at large. Care should be given to the child before it comes to school. If health maps could be furnished to people 434 showing the places where disease and death lurk they would hi a powerful effect. If parents are invited into school, it would be easy get them to act on physicians' and nurses' recommendations. It may dangerous to compel people to have things done to children. Dr. a. M. Stowe, president, Toledo Municipal University. Tole University has shown its appreciation of the importance of disease p) vention and health preservation by giving courses in hygiene and sai tation. Toledo University laboratory is now at the disposal of the c and could be placed at the disposal of the county if the county hea unit plan were adopted. Something ought to be done for the avera man or woman in the way of helping him preserve health. The couni will one day come to genuine preventive medicine. If there were i dustrial physicians, many diseases could be caught in their incipient Many people who are ill are unable to get the services of a physici on account of expense. Financial considerations govern in many caf of illness so that the persons do not get the proper service or th have a load of debt hanging over them after they are restored health. When a serious case arises that attracts interest the communi is always ready to help, but little is done when a man loses out throui sickness. Men who have been across the seas fighting for a great id( will be less moved by financial considerations and more by humanitari: motives. In answer to questions Dr. Stowe stated that he thought the pub! should help men to get adequate medical service when ill. John J. Quinlivan, vice-president, State Federation of Labc While labor men generally favor sickness insurance, old age insurance i pensions and sickness prevention, there are many diversified ideas co cerning them. Prevention is the biggest thing as it was in the wor men's compensation where prevention was the principal thing contei plated. If both employers and labor men understood the problem health adequately, it would ultimately mean a large increase in produ< iveness, more pay for the worker and conservation of health of t community. Educational work may begin with the infant. "I belie that ignorance is responsible for a good deal of our sickness." "^ practical demonstrations were given, a man would ultimately recogni the importance of these things. Questions also embrace many othe from the workers' standpoint, including the question of hours, sanita workshops and living wages, as well as fitting men to the tasks to performed. If workers are on too long hours, there is a lower resistance. The Commission should get down to the roots of t matter. Education will be important so that workers "may be i telligently able to protect themselves." In answer to questions, Mr. Quinlivan expressecj doubt as whether a man should be compelled to change his occupation after 435 had mastered it. Examinations should deal with the selection of kind of work. Half the present sickness could be prevented. Sickness should be covered by insurance. Long sickness almost invariably forces a worker to charity and surely to great sacrifices. Most workers are about a week before the pay roll. Workers must be educated to physical examinations as there is strong sentiment against them now among labor unions on the ground of discrimination. Examination under auspices of the state might eliminate the sentiment. Mr. Tillotson, Employers' Association. Mr. Tillotson said that he had talked with Toledo employers with the result that he had found nearly every employer had little definite opinion except to say that if a satisfactory plan could be worked out which would be for the benefit of the workmen, and if the plan were feasible, employers would be in favor of it. He had no suggestions. Many Toledo employers spend large sums of money in health preservation. Some of them have found it beneficial to the workmen and if it is beneficial to the workmen, it is beneficial to the employers. In answer to questions, Mr. Tillotson stated that employers feel that money spent for sickness prevention is not only beneficial from a purely business standpoint, but benefits the community as well. Employers are perfectly willing to spend all the money necessary for this sort of work. George Lewis^ employer. Mr. Lewis said that a concern in Peoria, in which medical service was provided, found that men who were about to be physically disqualified, under the guidance of physicians, were restored to health and productive capacity. The matter was not regarded from a mercenary or profiteering standpoint, but largely from a welfare one. If a person had been temperate, industrious and frugal, he or she should be cared for in old age in some proper form. Money should be collected for this purpose through the regular system of t^fxation. N. P. Usher, employer, formerly a labor union man. Mr. Usher hoped that the Commission would see its way clear to present at least jTa^bill for old age pensions for nothing is more pathetic than to see aged persons thrown on the charity of children or friends. Pensions should be paid directly from state funds. Perhaps it should be a national rather than a state affair. Prevention of sickness is a most desirable thing, but it is not altogether clear whether it is advisable at this time to enter upon sick insurance. "I am opposed to the physical examination by the employer of persons seeking employment." This would result practically in penalizing the workman. The state must provide something and should do something to help men return to a complete state of health. "I think the state has an obligation to the aged people of this state to protect and support them after they have 436 reached the age of 65 or 70. They should be supported by public tax- ation." In answer to questions Mr. Usher stated that the pension should be $8,00 or $io.cx) a week and that there should be a 15 or 20 years' residence requirement. He would make no distinction between the cases of a man with $1,000 or one with $1,500 but a man with $50 a month income should not get any pension. The inheritance taxes would be a proper source for old age pensions. Dr. W. H. Snyder, physician. The only thing with respect to health insurance upon which the medical profession can go is the experience of Germany and England. "In neither one of these is it satisfactory." Germany tried it for 25 years. Where they were la.rgely farmers and where questions of malingering did not enter largely, it was quite satisfactory. But in 1911 there was a feeling that the insurance funds were taking advantage of the physicians. Then, too, every city of any size had a good hospital and in many of the larger cities there were complete university stafifs. It was possible for physicians to make use of these facilities in diagnosis and treatment. In the large industrial centers there was a noticeable increase in days of illness. Men in favor of health insurance said this was due to the fact that these people never before had had an opportunity to be cared for properly. In mental diseases and complaints there was an increase in morbidity because men were not going back to work as rapidly as they could. Lack of hospitals and diagnostic facilities made the problem of establishing health insurance a very difficult proposition in England. ^ Dr. Snyder met with the British Medical Association in loii and he fwas struck by the consternation on the part of men who had stuBied it on the continent that it was to be tried in England. It worK^ tor a year or so, but in 1914 he was again in England and found tl*t it was just on the verge of breaking up. That was due, largely, to the fact that there was only one class of physicians that could succeed 5, under it. Medical men who were dispensing pharmacists, "Wjt 0°% doctors, could see men at six pence (12 cents) each and with ive^ja^^ hours these "pill dispensers" could make money. "Those were [thM only men that were satisfied." Sir William Osier said medical rnen' could not keep abreast of the times. The system was nTiiVitiiitin brrialr nr^ when the war came for they could not send, cases to hospitals to be j properly diagnosed. One cannot treat American artisans as one would4 treat artisans of England or Germany. The American wants to be treated as an individual patient. Maternity benefits, were inadequate and no American woman would think of applying for them. From Germany no information is to be obtained but the system was so bad that the government was sending back from the front physicians on salary to look after in_dustrial workers. 437 "The objection that the medical profession has to health insurance is that it does not take care of the man who wishes to do good work. He is penalized." Conditions are not ready for health insurance at this time. Workmen are not particularly desirous for it. The solution is in preventing disease. The first thing needed is a strong centralized state board of health, which would have control of county units. "There- fore, we are in favor of a strong county health unit, with a laboratory to make diagnoses — the state can pay for that, if it wishes — where a man can go and where a correct diagnosis can be made." No single man is able to make a complete diagnosis. It would take a group of four or five medical men. In later years it would be desirable that the man at the head of the health system should be a doctor of public health. The medical profession would always be ready to help. In answer to questions. Dr. Snyder said that if it is physicians who suffer first it will be the public which will suffer next. He ad- mitted that the remimeration for English practitioners was low before the health insurance system went into effect in 1912. He had not seen the report of the British Medical Association in favor of health insur- ance, saying that he might read it differently from the questioner. From German letters received before this country went into war he had learned of troubles they were having in German cities. The difficulty was with the organization for one cannot get something for nothing. It was not a failure of administration; morbidity rates have increased. One trouble is in taking in people without knowing the hazard, which insurance companies do not do since they insist on examinations. There is a greater amount of sickness in poor quarters than where well-to-do live. He said that he had not seen the British parliamentary report which was stated by the questioner to be favorable. CLEVELAND, DECEMBER G, 191S William Gale Curtis, chairman, Insurance Economics Society. Mr. Curtis said that he had been studying the problems of health insurance. Preliminary statement of the Ohio Commission, he said, fshowed a vast amoiint of research work undertaken and accomplished. |The humanitarian principle forms the bed rock from which all other considerations spring, but the tendency is to resolve into charity. One must move to state and national economics wherein problems should be t considered. Granting the truth of statements of advocates of health in- surance, there are two major plans, one to pay for loss, waste and misery and allow thein to continue, the other to search out their causes and correct them. Poverty is comparative and can exist with good health. Sickness can be measured and. in Ohio the 2,225,000 wage-earners suffer a loss of nine days each year or 20,250,000 days at three dollars a day is $60,750,000. That represents the determinable loss but there is also an intangible one in physical impairment of wage-earners and of chil- 438 dren. Three major objections to compulsory health insurance are tha it is unconstitutional, that it would not correct the fault and that i would add to the state loss. Possibly the time has come to "substitati paternalism or bureaucracy for republicanism and to enter a new er; with socialism as controlling idea." It has been estimated by advocate that the system would cost 4 per cent of wages and this would be $81, 000,000. As the workers would get this back, the $45,000,000 to be paic by the taxpayers and employers is to be considered. Misery and wasti would increase. The niunber of disabled workers abroad increased frott 367 to 456 per 1000 or 40 per cent. The average disability period in creased from 5.09 days to 9.19 days or 80 per cent. The cost per capit. increased 134 per cent. In Ohio, applying this figure instead of 825,75c cases of disability, there will be 1,036,000 cases. If Germany's ex- perience is repeated the cost of $81,000,000 will amount to $189,500,000 "Opinions of our best authorities all fail to disclose sound economic reasons for introducing the measure." It is a "palliative or political sof at best." Bismarck proposed to use it to bind the working classes to thi state just as Roman emperors had distributed coin. Dr. Friedensburg who administered the system for Germany, denounced it as "demoraliz- ing and devitalizing." Lloyd George found poor physical condition no1 due to poverty but to neglect. William A. Brend, the most eminent Eng- lish economist, says it has failed signally in its primary object. Cali- fornia is the only commission recommending it and a "paid platform advocate" was secretary of the commission. In November the plan was beaten by a two and a half to one vote. The plan has been defeated in America as "uneconomic, impracticable and wholly un-American." Through proper means misery and sickness can be reduced, beginning with child care. It has been said that 60 to 70 per cent of illness is preventable. Tak- . . . . ., , -^sK-- mg 40 per cent as a conservative estimate, it is possible to make a saving of $24,ooo,cx)0 iti wages in Ohio a year, adding medicines would be $25,ocx),ocx). Comparing this with insurance leaves a fayorable balance of $70,000,000 a year for prevention. The Association of Merchants anci Manufacturers of New York has drafted a bill for health conservaticjH' The New York bill contemplates the reorganization of the hea^; dies partment by the creation of a health commission, a healthy council 'tra sanitaiy districts. Each county is a district. There are ten majoj divisions of work and research, each under a director. There are threi funds, sickness, physical examination and general expense.. The bil would coordinate all the health machinery of the state. "Prevention anc conservation. are and must remain the only sane solution for the socia ills that beset every state." In answer to questions, Mr. Curtis said the wage-earner now bean a wage loss of" $6o,cxdo,ocx) annually. He said that he believed in work •men's compensation laws. Compensation is the recognized liability, tha 439 industry creates. There is no charity in it. He agreed, however, that a large percentage of accidents are not attributable to industry but are attributable to violation of rules, to neglect and other causes. Health insurance, he said, contemplates that the burden of charity shall be made that of industry. He agreed, however, that determinable occupational diseases should be covered by workmen's compensation. He did not think tuberculosis was determinable nor that industry is responsible. Having been told that Dr. Frederick L. Hoffman said a part of tuber- culosis in the dusty trades was due to the industry, Mr. Curtis said that he believed it was due to the manner of living outside the industry. The Attorney General of Wisconsin, he said, held that a health insurance law such as that proposed would be unconstitutional, for the prime reason that 20 per cent would be contributed by the state. It attempted to place a burden on employers which could not be related to them in the conduct of their business. Mr. Curtis said that the working people are against health insurance. He claimed also that employers are against the plan for health insurance but he admitted that he had not seen the report of the committee of the National Associa- tion of Manufacturers nor that of the Boston Chamber of Commerce. Mr. Curtis also said that the New York Medical Society was against health insurance as well as the Illinois Medical Society. The American Medical Association has never acted. He would recommend $5,000,000 expenditure for health in Ohio. Mr. Curtis admitted that a workman long ill under present conditions must rely on charity. John B. Andrews, secretary, American Association for Labor Leg- islation. In an outline of the progress of health insurance Mr. An- drews stated that the first general conclusion reached by those studying health insurance was that sickness is one of the principal causes of de- pendency. A meeting of 150 executives of social agencies decided to recommend the extension of insurance to sickness. It is recognized there should be universal medical care of all employees and a system of cash benefits, to tide over sickness periods. The California commission tijecomnjenjded health insurance. The Pennsylvania commission has found -fh«;.^«pd. In Massachusetts, one commission recommended and a second ^!^^d it. Wisconsin and Connecticut are studying the question. New jersey has-tecommended it. I The American Federation of Labor at its 1918 St. Paul convention *said that workmen's compensation laws have been followed by favorable sentiment on health insurance. The executive council of the federation said; The organized labor movement approved the enactment of workmen's com- pensation legislation. Their approval of that legislation was based upon the theory that when the earning power of a worker was impaired by reason of an industrial accident, that he and his dependents should be conjpensated during the time he was suffering from said injury. The same rule holds good when the worker be- 440 comes iincapacitated through illness^ particularly illness due to his trade or occupa- tion. He and his family suffer through the impairment of his earning power just the same as when he sustains an injury. The organized labor movement of America ought to formulate a program upon this subject. The convention authorized the executive council to make an investi- gation of health insurance particularly as it applies to trade or occupa- tional disease. If approved, a model bill will be submitted. Only two resolutions were before the convention, one proposed complete adoption^ while the other asked for an investigation of the financing of the advo- ' cates of health insurance. The American Medical Association has a committee at work while the president-elect, Dr. Alexander Lambert, of New York, is a pro- nounced advocate, but the association has taken no action, either for or against health insurance. After five years of operation the British Med- ical Association approved the English system of health insurance, saying : The degree of unanimity so far disclosed is somewhat remarkable. . . . That the general system by which the state provides medical advice and treatment under the insurance scheme is in the main approved and that criticisms have a tendency to concentrate on a comparatively few points which, though of great importance and indeed vital to smooth working, are, after all, matters of detail that ought to be capable of adjustment; that there is a large body of opinion in favor of the extension of the health insurance system to kinds of treatment not at present provided for and to classes at present excluded therefrom. While the British labor war mission was in this country it was asked as to the talk of wiping out the British insurance system and they said it was all "tommy-rot" and that proposals to abolish health insurance would precipitate a revolution. Proposals to include occupational diseases under the head of work- men's compensation is not adequate since the list of occupational. diseases which may te clearly defined is very limited. The additional protection afforded by occupational disease compensation to that afforded by healthy insurance will not be more than 2 to 4 per cent. It has often been said . that health insurance is mere socialism and yet again that Bismarck put it in effect in Germany to head off socialism. As: an example of mis-> information that exists, it is asserted in some states that the Ohio plan*^ of workmen's compensation is a failure. One authority has said that gw per cent of the opposition to workmen's compensation was due to misrep-^ reseritation and it may now be said that 90 per cent of the oppositioii| to health insurance is due to misrepresentation. In answer to questions Mr. Andrews stated that stopping payments at the end of 26 weeks would turn people over to charity. The proposal to give medical benefits to the members of the insured worker's family when' needed was explained by the statement that society as a whole should take care of the matter. Insurance can be used as a means to 441 better conditions as it has done under the Ohio workmen's compensation law. Health problems in this country are not visualized. Industry will favor a health insurance system when the proper plan can be worked out. Arnold Bill. Labor organizations feel that old age pensions con- stitute a sound policy and there can be no substitute. Labor men recom- men a minimum pension of $5 a week with arrangement for contribution in order to secure a larger allowance. Workers think that the pension should be a state function administered through a pension department. Pensions should be paid to all those who need the allowance to maintain themselves. Pensions should also be paid during invalidity. Where old people own a home, a pension should be paid and from this property the state should be reimbursed after they are dead. The minimum age should be 65. If possible, pensioners who prefer to wait, should re- ceive a larger pension. Corporations, fraternal societies and trade unions should be given power to insure their members for old age benefits. Voluntary loafers should have no pension. Those unable to care for themselves should be cared for in institutions. The county infirmaries should be abolished. Before a man is entitled to a. pension he should show that he has done his part in creating some of the world's wealth. He should be a resident of the state for at least 15 years. Twenty-five dollars a month is enough for an aged man to exist on. Old age pen- sions may be a federal proposition. Health insurance should be federalized. Irrespective of whether it is called socialistic, there is necessity for it. There are no existing agen- cies to meet the need of health insurance. "Poverty is the cause of sick- ness more than poverty is caused by sickness;" There is less liability to sickness among individuals properly housed and with funds for food and clothing. There is no question but that sickness insurance will bene- fit the average working man who has a period of sickness of a week or two which brings him down to the poverty line. In a general way health insurance is approved by workers. Health insurance which provides medical care should give a lower sickness rate. The state should pay one-third, industry a third and the workers a third. Health insurance ■ ,, should be entirely a state function. f^"*' Boris Emmet, United States Bureau of J^abor Siatistics. Mr. * Emmet told of a survey made by the Bureau of Labor Statistics of volun- ( tary sickness insurance in industrial establishments and la)bor unions - The principal purpose was to determine the degree to which it was voluntary since complaint had been made concerning the compulsory feature. The investigation showed that where sickness benefit funds w;ere voluntary, they did not work. Where a fund worked, the compul- sory feature was involved. In trade unions this was brought about by a resolution to the eflfect thiat membership in the sick fund was coexistent" with membership in the union. As an example the bakers' and con- 442 fectioners' fund was cited in which originally, less than 2 per cent chose voluntarily to belong to the sick fund. Voluntary relief establishment funds are so in name only. Some sort of force is apphed in getting men to join the fund. The average worker has to be educated to the value of insurance. Mr. Emmet estimated that one-fourth of the membership of the American Federation of Labor belongs to a sick fuiid in a trade organization, i. e. that between 600,000 and 700,000 are insured in labor unions. About 1,500,000 are insured in establishment funds. The typi- cal benefit is $5 a week in cash without medical benefits. The low benefits, explain the low sickness rate shown by their membership. Many trade union men say that the reason men do not put themselves on the sick benefit list is that benefits offered are not sufficient to give them relief. During unemployment the sickness rate increases. One objection to trade union funds is that often a man must establish his right to benefits before the entire lodge. Establishment funds in the United States have not been a great success for the employer is not enough of a specialist to run an insurance society. Those run by employees are not well man- aged, with the exception of the railroad funds. However, the great burden of sickness, the medical co,st, is not provided for. In answer to questions, Mr. Emmet said that any voluntary plan would never be a success. Any plan recognized for carrying insurance should have government approval. It would be better if social insurance were a new proposition. No man should draw benefits of more than two-tbirds of his weekly wage. CLEVELAND, DECEMBER 7, 1918. Dr. Child, head of the health supervision department of the Cleve- land schools. Dr. Child described beginnings of the work when children were found with sores on their faces and often lice in the hair. Parents were called in and instructed in the care of their children. He told of an instance where a child in a foreign section died of diptheria and where other children gathered around and kissed the corpse. The Chamber of - Commerce was interested in the revelation of conditions and a law was- secured giving permission to schools for medical inspection. Many schools now have school dispensaries. Weak children were put in open-r; air school rooms. It is not only humane but economical to educate igr child out of tuberculosis. Cleveland now employs 20- physicians and 32 nurses. Physicians receive $100.00 a month for part time. The nurse' acts as a clerk when the children are called in for examination. Notes are sent to parents which tell them of defects, such as bad teeth, etc. City provides free dentists. The aim is to send the child to its family physiciaii for adenoids, bad tonsils, or defective vision. Last year the inspector found 21^018 cases of defective teeth and succeeded in getting 18,023 into corrected condition. They also found 5,053 children with en- larged tonsils and secured correction of 1,422. Of 1,568 children with 443 adenoids, they secured correction in 993; of 2,625 children with defec- tive vision they brought 1,256 to correction. If the state can compul- sorily educate children, it ought to furnish the means by which injuries ta children's health can be detected and cured. The total number of defects found last year was 32,918 and corrections were secured in 12,544. This was in an examinatiori of 50,000 school children. In answer to questions. Dr. Child stated that the school physicians vaccinated 45,972 children. They found 13 cases of tuberculosis that might be communicable and the children were excluded from school. Health supervision should be under the departmeiit of education. Ex- perience has shown that there was little duplication with health author- ities. For parochial schools control by the department of health was suggested. The principal trouble now is the lack of a follow-up system. Sometimes in extreme cases parents of children with serious troubles are taken before the juvenile court and are required to defend themselves against charges of neglect. Forty per cent of school children have some defect that might be corrected. If "adequate physical and medical care" were inserted in the law, compelling parents to look after children, it would be easier to secure results. The trouble with control by the health department is the insecurity of tenure of office and pohtical consideration. Howell Wright^ executive secretary, American Association of Hospitals, secretary, Cleveland Hospital Council. The proper solution of the problem of health insurance is of great interest to hospitals and dispensaries for the reason that the fundamental basis of such insurance should be medical treatment and rehabilitation so far as possible of dis- abled wage-earners. Before there is any scheme of sickness insurance, there should be adequate hospital facilities. There are not enough hos- pital and dispensary facilities now to care for the sick. It is easy for the wealthy to get proper hospital care. "The poorest people also get the best -.there is." But it is exceedingly difficult for the so-called middle class, the respected wage-earner, for the man who has a fairly good in- come, but 'who cannot pay for the high-priced rooms, and who at the ^ame time does not want to be an object of charity. For that group of persons he would make an appeal. Mr. Wright said that it would be "costly. Hospital arrangements under workmen's compensation are not satisfactory. Often hospitals secure only a small part of their actual outlay. Because of this, rehabilitation of injured men is .often not car- ried through. He was much interested in the public health proposals of the Commission. In answer to questions Mr. Wright stated that the hospital associa- tion had taken no steps to get additional hospitals into communities with- out any or with too few. He opposed state control of hospital facilities. Health insurance would stimulate the prevention of sickness. If there were no stimulus to the creaCtion of hospital facilities, it would be a safe 444 observation to say that in ten years the state would be as badly oif for hospitals as now. In Cleveland they had had to turn the venereal ward of the City Hospital, which was badly needed, into one for influenza. James F. Jackson, Cleveland Associated Charities. "Approxi- mately one-third of the families we deal with are in poverty because of sickness." "When one-third of the families with which we deal are brought to poverty because of sickness, it means that a very much larger number of families are brought to an approach to this situation becau^ of sickness." Charity is broader than giving of alms and all people are recipients of charity, no matter how rich. Sickness could be greatly re- duced by adequate measures. In answer to questions, Mr. Jackson stated that the group of people who are relieved is a constantly changing one and that professional pau- pers are not numerous. If the state had not been so parsimonious it would today have fewer feeble-minded and insane persons and paupers. The causes of poverty are sometimes mutual in that sickness causes pov- erty and poverty causes sickness, but this is not so often true among the normal working class. Preventive measures and education will be of great value. His impression was that health insurance would result in better medical service. The individual has no control over ailments that ' cause most trouble. Dr, H. N. Cole, in charge of the venereal disease campaign for State Department of Health and United States Public Health Service. The subject of venereal diseases must be considered very seriously in any plan of health preservation. Ten per cent of the people of Ohio, or 528,000 are affected with syphilis. It is estimated in New York City that eight out of every ten young men have gonorrhea. The reports of disease and deaths by disease are far below the real facts. ■ Syphilis is the cause of 20 per cent of insanity; hence, 1,800 patients in state hospitals are there because of this condition. Many still-births and premature births are due to venereal disease. It is a disputed question whether venereal dis- eases should be covered under health insurance. It is estimated that 5 per cent of the cases of syphilis are contracted innocently. A law to forbi^-' druggists prescribing for venereal diseases and to prohibit advertisementsi* with respect to them is urged. Under the ChamberJafn-Kahn act th'ere^ will be available as the federal government's part of* the contribution. tod the State of Ohio $51,000 in fighting venereal diseases. The national government is giving a million to the various states. Venereal diseases j under regulation must be reported and provision is to be made for pre- venting their spread. The travel of infected persons will be prohibited. The measures which will be taken will include the detentiafi'of those who might contaminate others, the extension of facilities for' early diagnosis and educational work. A state farm for women where curative treat- ment can be given is heeded. Wards in hospitals for treatment of cases 445 have already been secured. Placards will be placed in toilets of railway cars. Lectures are being given to high school boys. In answer to questions Dr. Cole stated that a farm was recom- mended for prostitutes because the plan has worked well in other states and because women can be isolated and really properly treated. The resolution- of the Public Health Council authorizes the arrest of persons suspected of being sources of infection. Druggists already have said through their association that they do not wish to engage in tht business ■of selling medicine if it is harmful. Physicians themselves, however, sometimes prescribe patent medicines — "606" is, however, not now called- a patent medicine. "VS. Dr. Edward Spies, Western Reserve University. Dr. Spies said that he did not know where druggists stood on compulsory health in- surance. . The profession of pharmacy is interested in the administra- tion of health insurance. The organization has been wondering whether there will be a scieritific man to purchase drugs for treatment or whether they will be bought by those who know nothing of drugs. The drug, end should be handled by men who know about drugs. In answer to questions Dr. Spies asserted that a reasonable bill could not be objected to by the druggists. Many druggists would wish to get out of the patent medicine business if they could- do so without bankruptcy. Diagnostic clinics would help to raise and keep high the standard of the profession. Don C. Sowers, director, Bureau of Municipal Research of Akron. The passage of a' law for preventive measures and the establishment of machinery will not accomplish the desirejl result. The extent of sickness warrants a state wide plan. Existing facilities cannot take care of the situation. Thirty to forty per cent of poverty is directly due to sick- ness. ' Ample and efficient medical care would have a . tremendous in- fluence on sickness. The state is not ready for health insurance. If it should be applied it should apply to all regardless of salary.' Employees jn small working establishments should not be included immediately. In ':tbe ease ofgnarried men, benefits might be two-thirds of wages and half ■*OTwages'To sihgle men. Payment of benefits should not be limited to ■ any .d.gfinite period of time. It does not make much difference how the payment of pireimiums is distributed between workers and employers since it is all paid for by society -in the long run. .The principal problem is the rehabilitation of sick men. '••'X^ompensation should be made de- pendent upon observance of rules of conduct. * In answer to questions, Mr. Sowers stated that he considered a dis- tribution of 40 per cent to the employers, 40 per cent to the workers and 20 per cent to the state would be about right. The Charity Organiza- tion Society of Akron favors health insurance. 446 Don Stevens, Goodyear Tire and Rubber Company. Social in- surance should be studied more carefully after sickness prevention measures have been tried. Most Akron industries have adopted, some plan of health insurance and old age pensions. Large corporations will be able to carry the load better than the small ones. Because of state competition, a national movement for social insurance may be more de- sirable if there is to be any. Other countries have health insurance as a national proposition. If health insurance is proposed there should be a system by which the employer may carry his own insurance as in work- jnen's compensation. The cost of and the necessity for health insurance might be much reduced if sickness were properly combatted. In answer to questions Mr. Stevens stated that the Akron Chamber of Commerce is open-minded on old age pensions. Goodyear Tire and Rubber Company has a relief association which was started by the work- ers themselves. Mr. Woodward, president, Cleveland Industrial Association. In- dustry often bears the cost of sickness because of poor health conditions which cut down productivity and which increase the costs. The Cleve- land Hydraulic Pressed Steel Company is contemplating insurance, for it considers that it is responsible to employees and it does not wish to- shirk that responsibility. In answer to questions, Mr. Woodward said health insurance may be a good business proposition, of mutual advantage to both employer and worker. Home conditions are a factor for a man cannot do good work with a sour stomach. Health is a part of the job contract. Any- thing which is constructively building would be welcomed by industry, it would seem. It seems repulsive but it may be necessary to- visit a sick man's house to see that he cares for himself in a proper way. It would be proper to have a, law for sanitation of premises. Dr. D. B. Lowe, Goodrich Company, of Akron. Dr. Lowe favored an extension of public health work and preventive medical work in OhioK, He also favored the principle of health insurance and granting old age pensions with the proviso that the pensioner may increase his allowance 1 by contributions. ■'. .< Prof. Charles Geb.l.ke, Western Reserve ^Unitrersity. It appear&.v? impossible to reorganize the medical profession in anything like an ade- ^ quate way except by making medicine a branch of the public service. Preventive measures are needed. A complete program of health preser- vation work must be organized. There must be some kind of insurance which probably should be compulsory. J. M. Hanson, of Youngstown. With the creation of a health in- surance plan there will be created new agencies which will promote. so- 447 cial well being. If the state has the right to compel school attendance it has the right to compel attention to physical needs so that the child may henefit by the instruction given him. The machinery for school medical work should emanate from the department of health. Children also should receive medical attention before they go to school. Sickness ^may be largely reduced by proper attention to sanitation. DAYTON, DECEMBER 16, 1»18. Mrs. Cqewin, hospital investigator. Old age dependency in many instances is due to sickness. When people pay for hospital treatment, even though it may not be sufficient to cover the entire cost, the sting of charity is removed. Wage-earners in general cannot be sick more than two weeks before they becotne dependent. Wages were higher last year, but the increased prices have largely eaten it up. Although more sick- ness comes from poverty than poverty from sickness, yet it is a fact that the wage-earner may become sick because he is poor and because he is sick is then unable to earn. People living under poor conditions are less healthy. C. D. Hoffman, Associated Charities. Seventy per cent of poverty is caused by sickness. During sickness the wage-earner tries to bor- row and then comes to the Associated Charities. The average workman can protect himself by saving. Dr. E. L. Crew^ Miami Valley Hospital. One-half of the workmen i could carry an illness of 13 weeks. Dr. H. G. Barr, National Cash Register Company. This company does not 'employ physically undesirables. It gives men advice on health protection. It employs a visiting nurse who is kept busy making visits and a dentist. The company allows men to take baths on company's time. Absentees run 2 or 3 per cent. The company also has a volun- tary relief organization with 2,500 members which has been running for 25 years. Tt provides free medical aid and a cash benefit of $7.00 a ■vyeek for 13 weeks. The association has been able to weather influenza rfepidemic. Only two men in 10,000 have objected to the physical ex- aminatioft) iwhile 98 per cent feel it is for their own good. M.^s^';WAi.f^/.head of the Visiting Nurses'. Association. People ^etetally 'fiavS no complaint to make on the work of the visiting nurses. TTjp!, city pays for the supplies used by visiting nurses. The association now has 17 nurses and needs 17 more. Dr. Brewer, dentist of the National Ca^h Register Company. The company ^maintains no follow-up on dental inspection, but if a man in six ;fionths has not followed recommendations, or given good reason for not doing so, he should be- discharged. Among 1,200 men only five sets of perfect teeth were found. Many ills are due to bad teeth and teeth 448 ' ''■■ ("-, well cared for will reii'ticc sicknesS. There should be dentsd and pi: Hispectinn. •■"- , ■' ' Ijk, Peters, city physician of Dayton. There should be mecSldfe examination's in the schools. The hope ^ri ' ^;alth wofk i.'i Tie children" PubHcity is a great help in educatioiial Vi^ork in health. Dangefous c^ses of contagious diseases which are a menace to others should be seg- regated. Milk and meat in';p?c<*ion -o .^quate. Housing conditions are poor in rnany districts of the city. Nothing is so destructive as 'a', badly ventilated house. Ashes, tin cans and rubbish matter little. Ru^fel^ communities need as much health work as citie*.. j.._xe should be 'a,i uniform county system of |iealth which., should include the city. There should be'a county laboratory. Physicians are needed as health officers. Health activities in Dayton have produced splendid results. , '{ J. L. .jivi]Tii, secretary ^■'^ •*?• • ]%hor unions of Dayton. "The state should have given old age pensions many yes-rs ago.' The factory 'c(Jde.' o.f the state "has not been made cF-tive. Illness due to poor factory conditions puts a heavy tax on unions' pio .'Ing sick insurance. , With - proper sanitary arrangements the health of the men would' be greSfty impF'oved. If factories were compelled to pay half the cost, of ins-u^'anc'e they would be more careful of the health of the men. Workmen's com- pensation law has improved the accident side. ^_ '"■. J. "i" Smith, Retail Clerks' Union. Tn'urance might not be so bad.*-; for the State of Ohio. Seventy-five per cent of workmen need insurance. The weekly pension for old age should be $12.50. "i ■*'- Mr. Chapman, Belgian workmen. Hc-si^id that when lie came from Belgium the first,thing he asked aboflt was the old age insufgftge and sick benefit System, fit praised the .system in the-"old country."; An oldi'^^gg' pension should be on the plan 5f the employe?, contributing hilf aiid the wdrkmsSi lial£ ■ ~ ■ ■*,..■■ '' , ,", - ^._, 4^ J.,' ,-4,. ^■,. •»■'■' ■'■■), ■'^*r ..-?*-. tvIrs. J.,Pr:'S]v(iTH. Mrs. Smith handed in one of'ithe:;^rst^petition% for, old age 'pensions. People should- be_ here 20 years before* aApension is given. The public is. ready for old age pension, ' .^ * * ■-. . ' .« * - ,■■<.■ "-i.PR.' HousT(?N. Health insurance,is oiiG^^an origin and ■wrould, not -fi* into "liberty-loving America." People would be pauperized. Physicians would* lose all enthusiasm when paid in advance Gy_ if they knew^^that tl;iey were to b^ paid in any case. Men working 1iy.,th,e,^ear will get to the point where they will' not w^. to work. Now' i^k,ex-^' penditure is 27 cents for each, persoti,,£or fiealth;; $1.50 f or 'eatjhj^lrsoh. for fire protection and the same amouift for police ^protection" The state lias no right to interfere \vith individuals as fg'S^instance in the use of water. Health authorities are restrfcted by lack of ftiii'd^"^ . ' Cornell University Library ID7102.U5O31919 Health, health Insurance, old age pensio 3 1924 002 406 977