Medical Insurance 2012 or 1903?
"Government Aid or Self-Help"
by Alfred Adler
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Government Aid or Self-Help (Part 1)
Our profession can no longer ignore the basic problem of how to gain the government's support for the improvement of public health. The medical profession itself has not been clear about how to improve health care, leaving the government also in the dark about necessary legislation. Aside from general recommendations to the public about self-help, the division of responsibilities between physicians' organizations and the government has not been sufficiently articulated.
If we ask ourselves, however, what interest the government has in stemming the decline of the medical profession’s standing, the answer will not be simple. At times, we may hope for the appearance of visionaries who believe that the government has the responsibility for dealing with all kinds of problems, that it must have an ethical and humane character, that it looks to the future, acts with a social conscience, and listens not only to the wishes of the mighty, but also to those of the little people. Given our general political sophistication, we in Austria have certainly not distinguished ourselves. Instead of focusing on socially benevolent policies, our government is often preoccupied with criticism of social visionaries. Year after year, our quick-changing governments show us that their only concern is in the business and interests of the politically influential segments of the population.
Are the social measures passed by various governments to protect the weak an exception to this point of view, or do they present contrary evidence? They do not. Those familiar with the history of our government’s social policies know that the minimal demands for protecting the poor represent merely the shabbiest progress in worker protection laws wrestled and wrung from the ruling circles in the face of the massive weight of the working class. Therefore, whatever the heads of government agencies responsible for this problem had achieved does not deserve special recognition or praise, any more so than the work of a machinist who reduces friction with oil.
The challenge for physicians chosen for this task is to reduce friction. At one time, when physicians were considered essential by the government, their status was much higher and even politically influential. As long as the whole country was infested with many diseases affecting both the poor and the rich, diseases that could not be held in check without the artistry of physicians, their elevated status was secure. We can even say that the respect for our profession stems from that time. However, when medical advances introduced modern hygiene, the ties of the medical profession to the entire population were cut. After outstanding medical preparatory work, that effort passed into the hands of technicians, who under their own authority assumed the task of guarding the health of the population. Then, under the pretense of meeting the needs of the poor for medical care, less than one half of that part of the population was provided medical insurance.
The medical needs of the ruling circles were provided by physicians employed in the regions and communities to serve them. These circles evaded even the most reasonable constraints by placing the practice of medicine under a bureaucracy. Tied hand and foot, and bereft of their inalienable right to free initiative, these colleagues of ours carry out their thankless tasks under the dictates of lawyers and politicians. They search in vain for influence or meaning among the population, and in no way do they increase respect for the practicing physician.
Other physicians function under a health insurance plan, where they are the essential component. The law specifically recognizes their indispensability. We need to ask ourselves: Does this insurance plan increase respect for physicians in the eyes of the people? Unfortunately, the answer is: no. The work of these physicians is looked at askance and the physicians themselves are often at the command, and even slaves of, the insurance organization. The organization’s leadership is bound by its profits and keeps both physician and patient as much in check as possible. This is not to argue against self-government, a term associated with the political influence of the workers’ union, and as such, deserving respect. However, no fiendish mind could have fashioned this three-cornered relationship of insurance bureaucracy, physician, and patient in a more ugly manner. In order for these insurance companies to maintain their power, profit, and privilege, they resist all social progress, leaving improvements in health care at a standstill. Instead of improving health care and promoting mutual trust for the good of all, this system breeds nothing but destructive mistrust. Had physicians won the trust of people with passionate concern for their needs and diligent involvement in meeting those needs, clarifying their rightful leadership role, then their importance would undoubtedly be recognized. Certainly, a greater respect for the medical profession would have a beneficial impact on all social legislation.
Does anyone believe that the ruling elite has the slightest interest in improving health care or the standing of the medical profession? Our rulers can calmly postpone any social progress. Without a sufficient reason, and the medical profession seems unable to give them one, would they willingly agree to diminish their powers with new social initiatives? Our government, consisting of leaders of the politically influential class, has given the medical profession little help, and did so begrudgingly. What remains of the physicians’ standing is minimal, thereby having limited influence on the improvement of public health.
In view of what has been happening over the last few days, we could save ourselves the effort to continue with the observations that follow. The debate in the Landtag and the address by the representative from Lower Austria clearly demonstrate the status of the medical profession among the leading circles, and their low regard for physicians. Even more, the cited passages reflect the attempt by laughable means to debase even further the skills of physicians in the eyes of the population. As mentioned previously, we could conclude at this point and instead of further discussion, write: Under current conditions, the medical profession cannot hope for anything from the governing elite, nor is there any use in asking. We would delude ourselves to count on government support for the medical profession.
However, in order to continue our theme, we should still mention the military medics, who are unquestionably regarded as a necessity. Subordinated to a particular discipline, they are separate from the medical profession, and fall outside the scope of our observations.
Insofar as the government now employs permanent staff physicians for its most essential functions, such as the police and the military, it could not resist placing under its authority medical research and the teaching of medicine. Because medical science has the potential for enormous development, the ruling factions want to keep it under their control. Medical research must not develop unbridled, but must keep pace with current, floundering social measures. For the same reason, the authorities appoint teachers, limit the growth of our schools, and begrudge the teaching of essential subjects in hygiene and social medicine. By limiting research, education, and development, the government hopes to prevent internal conflict, friction, and rebellion. However, we pay dearly with the diminished reputation, integrity, and effectiveness of our medical schools.
Because a country obviously needs a medical faculty, the government ensures that most training clinics are adequately staffed. The teachers’ task is to train a necessary staff of medical administrators, required by the government to supervise the medical profession. As long as the population in cases of illness still seeks the counsel and help of the practicing physician, the government must provide training for this profession. Finally, the affluent also want to be able to use practicing physicians and specialists.
As unsuitable as this system is for furthering the development of the science of medicine, it nevertheless satisfies the most basic needs of government and the wealthy. However, it can achieve nothing more. The decline of Vienna’s medical schools is primarily the fault of our ruling class.
We would, of course, not ignore the importance of independently practicing physicians who serve a part of our population. Their importance is due solely to their competence, compliance, and character, qualities acquired over many difficult years. However, throughout a physician’s career, recognition of his work is contested by those offering plenty of advice, but lacking any understanding for the need to improve preventive health measures. In addition, the ruling class systematically undermines the physician’s status in the community. The medical profession's passive reaction to this official disrespect will certainly further diminish the physician’s worth in the eyes of knowledgeable people, and perhaps even cause the call for community physicians in the countryside to slowly subside.
As comfortable as this system might appear to some, the inherent contradictions in the performance of the medical profession and the problems created by the government are so enormous that time alone must destroy that system. However, even the most modest progress that the medical profession can achieve will always be countered by that system. To expect help from the government would be utopian, if not foolish. The medical profession can shape its future only by its own powers.
1 Originally published in Aertliche Standeszeitung, No. 21, Vienna, 1 November 1903.
2 New translation by Gerald L. Liebenau, 2002.
3 Originally published in Aerztliche Standeszeitung, No. 22, 15 November 1903.
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CCWAA: Volume 6 - Journal Articles: 1927-1931
CCWAA: Volume 7 - Journal Articles: 1931-1937
CCWAA: Volume 8 - Lectures to Physicians and Medical Students
CCWAA: Volume 9 - Case Histories
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CCWAA: Volume 12 - The General System of Individual Psychology
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