months the expenditure was within the actuarial expectation for that period, but that in the future it is possible that the disablement benefit for women and especially for married women may involve a heavier charge than originally anticipated. The combined effect of the medical care and the provision of cash benefit is that many who previously had dragged along without medical advice, forcing themselves day by day to work in spite of illness, have now for the first time had proper attention. Physicians have said, "I thought I knew how much illness there was in my neighborhood, but I had no conception of the amount that existed until I was brought in contact with it through the act . . . I had no idea that it existed, and was going unrelieved, and that people were dragging along with such illness." An official investigating commission states that "already there are indications that as a result of the rest obtained under the act a better condition of health has in certain cases been attained than has been experienced for many years."

The maternity benefit, it is calculated, went each week of the first year to 17,000 mothers and throughout that year 887,000 received maternity benefit, involving a total expenditure of $7,000,000. The results of the cash maternity benefit were soon discernible in the rapid decrease in the mothers seeking assistance from the outpatient departments of hospitals and from other maternity charities, and in their willingness to pay for what previously had been given to them, sometimes engaging a member of the hospital staff, but more frequently resorting to the midwife who often could be prevailed upon to give needed help with household duties. This increased use. of the midwife, trained and supervised though she be as in England, creates a new problem which can be solved only by providing the maternity benefit in much the same way as medical assistance is now provided for insured persons.

The effect has also been felt by poor law officials and charity workers. The poor law has been relieved of a large number of calls for medical care from the parish doctor, for midwifery assistance. and for out-door relief in time of sickness. In the towns of Bristol and Manchester the diminution in pauperism in 1913 as compared with 1912 is attributed to the insurance act; in the latter city the number of payments of out-door relief decreased by 30 per cent, while the actual amount diminished 25 per cent. Among the Liverpool dock laborers it is estimated that in half the cases which re

ceived sick benefit, the home would have been broken up and relief sought in the workhouse had it not been for the benefits of the insurance act. Charity workers, too, have found that the calls for financial relief have diminished both in number and in the amount of assistance required. On the other hand, some of the local poor law officials fear that the enlarged use of doctors brought about by the insurance act, which is revealing a larger number needing hospital care, may increase the inmates of the poor law infirmaries. This, of course, is significant of the higher standard of medical care for the working man resulting from the insurance provisions. Sanatorium benefit, notwithstanding petty jealousies between rival local boards, fostered by the administrative system, and the inadequate funds at the disposal of the insurance committees for their share of the work, was received by no fewer than 44,000 insured workers in the first eighteen months' operation of the act. Of this number, more than half were placed in sanatoria, others were treated in dispensaries, and still others were cared for in their homes by the panel doctor, under the guidance of the tuberculosis officer. To assist in home treatment 1,200 shelters for out-of-door sleeping were available, and in other cases milk and eggs were supplied to patients in their homes.

Moreover, the whole anti-tuberculosis movement has been strengthened. To provide the additional sanatoria necessary for the treatment of the insured and their dependents provided for in the act, Parliament in 1911 made a grant of $7,200,000 to defray part of the expense of sanatoria whether erected for insured or non-insured. Under this generous provision plans for 3,000 new beds had been made within the first twenty months and grants to the extent of $1,287,000 had been either made or promised. Following the recommendations of the famous Waldorf Astor committee that sanatorium benefit should be available not only to the dependents of insured but to the whole population, the government announced in July of 1912 that it was willing to bear one-half of the expense incurred by the local authorities in treating non-insured persons as well as the dependents of insured workers. For this purpose Parliament granted $1,464,000 and $2,300,000 for the budget years of 1914 and 1915 respectively. The provisions which have thus far been made are but the beginning of an effective crusade against tuberculosis, instigated by the insurance act and originally restricted to the insured and their families but later extended to the entire population.

If even a cumbersomely conceived plan of health insurance can improve health, decrease pauperism, and forge an effective weapon against tuberculosis, are not we Americans challenged to devise a system which will function more perfectly in our war against poverty and disease?

TENDENCIES IN HEALTH INSURANCE LEGISLATION

MARGARETT A. HOBBS

Special Investigator, American Association for Labor Legislation

The five years between 1909 and the outbreak of the European war saw rapid development in compulsory health insurance legislation. During that time such laws were adopted by the six countries of Norway, Roumania, Russia, Serbia, Great Britain and the Netherlands. The four countries of Germany, Austria, Luxemburg and Hungary had previously passed such compulsory laws.

All the laws cover practically all low-paid wage-workers. In the Netherlands and Norway workers receiving less than a given income are included, without regard to occupation, while the Standard Bill of the American Association for Labor Legislation, like the laws of Austria, Germany, and Great Britain, applies to all manual workers and to other low-paid employees. The laws are equally inclusive in covering all forms of sickness, while in Austria, Germany and Norway, the first few weeks of industrial accident disability also are compensated from the health insurance funds.

The benefits provided are of two sorts-medical assistance and cash payments. The Standard Bill follows prevailing European standards by granting the latter for twenty-six weeks, dating from the fourth day of disability, while medical attention is supplied from the beginning of illness as long as cash benefits are due. In most European laws these are only the minimum terms for benefits, however, and higher standards are permissible. Thus in Germany the waiting period may be shortened or entirely eliminated and under some additional restrictions benefits may be paid as long as fifty-two weeks.

The laws fix the minimum rates for cash benefits, but frequently allow higher rates as well. Minimum rates in Austria, Germany and the Netherlands vary from 50 to 60 per cent of wages, while a maximum of 75 per cent is permitted in Germany and Austria and 90 per cent in the Netherlands. England is the only country paying uniform benefits without regard to wages. The standard of the Association bill, 66 2/3 per cent of wages, is that of the best American compensation laws and falls between the extremes of European legislation.

The laws usually provide insured persons not only with medical treatment, but also with medicines, therapeutic appliances and, except in England, with hospital care. In England, however, provision is made for all forms of tuberculosis, which are entitled to sanatorium care. Medical care to the

dependents of the insured, which permits economical medical service and adds much to family well-being, is optional in Austria, Germany and Great Britain and compulsory in Norway and in the Standard Bill. While no medical benefit is furnished in the Netherlands, the deficiency is partly made up by the high rate of cash benefits, usually 70 per cent of wages, and by the numerous voluntary “sick clubs,” which must be open to any insured person.

Maternity benefit is provided in every European law. The insured woman usually receives obstetrical assistance and a cash benefit for four or six weeks at her confinement. Great Britain, conforming to the flat rate principle, gives a lump sum of $7.20 both to insured women and to the wives of insured men. The latter receive obstetrical care under the terms of the Standard Bill, and in Germany such care and also pregnancy and nursing benefits may be furnished.

European legislation empowers the insurance carrier to make contracts with physicians for medical service. Perhaps the most common arrangement is that of England and Germany, by which free choice among a panel of physicians is normally allowed. The four options of the Standard Bill, namely, choice among a panel of physicians, "reasonable free choice" among salaried physicians, district medical officers, or a combination of these methods, permit an adjustment to local conditions of the plans found successful in European experience.

A modest funeral benefit, large enough for decent burial according to prevailing standards, is also provided by all the laws except those of England and the Netherlands. In Austria, Germany and Norway an allowance of from twenty to fifty times the average daily wage is made; the Standard Bill fixes a maximum of $50.

The cost of health insurance is in every case met by joint contributions. These come in Austria and Germany entirely from employers and employees, but, under the other laws and the Standard Bill, from employer, employee and the government. England accompanies a flat rate of benefits by a flat rate of contributions; other countries and the Standard Bill vary the contributions according to wage.

In its administrative machinery the Standard Bill follows closely the provisions of all the laws considered except the British. The normal insurance carrier it sets up is a district local or trade fund under mutual management, but such other societies as establishment funds, labor union funds, and the like, may, with permission from the supervising authorities, also carry the insurance. In every case the "approved societies" must be mutually managed and cannot be profit-making enterprises. In Great Britain, where no district funds are established, and “approved societies" may contain members from any locality, there has resulted a clumsy and unsatisfactory division of authority by which cash benefits are paid by the societies, while medical benefit is administered by local insurance committees.

The "mutual management" of the district funds is that of employer and employee, with, in some cases, as in Norway and the Netherlands, representatives of the government also. Employees have a majority representation in Austria, Germany and Norway, and British "approved societies" are entirely controlled by their members. In the Netherlands and in the Standard Bill employer and employee are given equal representation. In every instance there is government supervision of the funds.