to enabling it to meet any situation that may develop as the administration of the law proceeds. It is at the same time subject to judicial review in the exercise of its powers, so there is no danger of its becoming unduly autocratic in attitude.

That is in brief the proposition the committee wishes to lay before you for consideration. Already it has been criticised at important points, and suggestions have come in which should lead to valuable amendments.

I want to refer especially to one criticism that has been urged upon us with great earnestness, by representatives of the Consumers' League, and that is of the maternity benefit-the cash benefit to employed women who give birth to children and are therefore withdrawn from gainful employment for a certain period. It is feared that this provision will encourage the employment of married women, and I think there is some ground for that fear as the provision now stands in the bill. That is to say, unless adequate safeguards are thrown about this part of the bill, it may have that effect. I have been especially impressed by evidence that has come to us from Mr. Howell Cheney, of South Manchester, Conn., since the bill has been printed. He states that he started out in the sickness insurance plan he has introduced for his employees with a very liberal maternity benefit provision, but found that the result was a large increase in the number of married women who sought employment in his mills and an alarming drain on the funds to provide the maternity benefit for these women. He met the situation, not by abandoning this feature of the plan, but by modifying it so that married women could not receive this benefit unless they had been employed for a considerable period and so that the benefit itself would in no case be more than $50, and therefore somewhat less attractive as an inducement to married women to seek employment.

The bill as outlined is laid before you not as a finished act but as a basis for criticism and discussion. Our Social Insurance Committee has labored over it long and earnestly. It represents a study of the strong and weak features of European systems, fairly intimate knowledge of American labor conditions, and unanimous conviction that the time has come for bold experimentation with health insurance in this country. The committee has not, however, any great pride of authorship in its work. It knows that the bill can be improved and strengthened in many ways, and to this end and to the end that legislation be secured it confidently asks your help.

GENERAL DISCUSSION

LEE K. FRANKEL, Sixth Vice-President, Metropolitan Life Insurance Company: I have been interested in the remarks of Dr. Emerson with respect to the measure of sickness. One of the facts that we shall have to determine, at least approximately, before we can estimate the cost of a health insurance plan is the sickness existing in a particular community. Unfortunately there are no data available, as far as the United States is concerned. A study was made, I think, in the '70's, but it was not a very exhaustive one, and is really not valuable under present conditions. In view of that fact, we have attempted in the last few months to try to ascertain whether we could get some idea as to the amount of sickness existing in a community at a particular time. For this purpose we selected two cities-Rochester, N. Y., and Trenton, N. J., representing widely different groups of industries. The information was secured through our agents from our industrial policy holders. Because of the intimate contact these agents have with the policy holders we believe that this was a very efficient method.

We inquired into the condition of 34,000 individuals in the city of Rochester, and found that 798 of them were sick. Of these, 82 per cent were sick and unable to work, while 18 per cent were sick and able to work. Some who were chronically ill, with rheumatism and the like, were still at their occupations. Ten per cent of the total number were in hospitals. Most interesting of all was the fact that 25 per cent of the total illness was due to diseases of the nervous system-a remarkably high ratio. Among these were sixteen cases of epilepsy, twenty-five of insanity, and a large number of paralysis and locomotor ataxia. I should say that I doubt whether we obtained any record of venereal diseases, and I believe we lost a large percentage of tuberculosis. But outside of these I think we found pretty nearly all of the sickness which incapacitates. Ten per cent were cases of accidents and childbirth. There were sixteen cases of whooping cough, four cases of typhoid. Only 60 per cent of the total number of cases had a physician in attendance. The other 40 per cent did not. We found that the cases where physicians were in attendance were acute diseases.

Another interesting thing is the duration. No fewer than 170 cases, including, of course, the chronic cases, had a duration of over three years. The Trenton figures, which I have not at present at my disposal, practically confirmed those obtained in Rochester.

Finally we have demonstrated in the survey what has long been known in German experience, namely, the increase in the rate of sickness with the increase in age. That increase seems to be alike, as far as the two cities are concerned. On the other hand, there is a higher rate of sickness for women than for men. That is something we must recognize here in the United States in connection with any scheme for insurance.

DR. EMERSON: We have recently been analyzing the death rate in various sections of New York City, and the first figures cover a section of the upper west side of the city. The employment of specialists has no doubt brought down the death rate in certain parts of the city where the well-to-do live, but in other sections the death rate is higher.

It is important to emphasize the advantages that may be expected from the supplying of funds to a family during illness. The continuance of nutrition is the most fundamental thing we must provide for. A tree will reveal in its rings of growth the lean and the fat years. So will the children of a community. Last year was a very lean year among the poor of New York, and we got a very large percentage of diseases among children, a great many respiratory diseases. These children were being starved into sickness. If one can assure the children, as they are growing up, continuous nutrition, we are going to go far toward health.

I should also plead that the clerks be not excepted. We have within the last six months made a study of the business offices in one of the large business blocks just off Broadway, in New York, and there, layered in twenty layers in some places, one will find hundreds of desks close together, the clerks who use them enduring insufficient ventilation, excessive heat, and poor lighting facilities, thereby severely affecting their health. Although we cannot say that the clerical work is what causes tuberculosis any more than numerous other causes, still it would be a great pity to exclude the clerical workers, because, due to the essential conditions of their environment, they have a risk which is not always recognized.

In a census of 31,000 people living in our District No. 1, we found 108 who were sick. Of course that was a very small proportion. Almost all the cases were due to digestive disturbances or to chronic diseases; there was no cancer, or syphilis, or the like, reported. We had a check on the tuberculous and communicable disease cases, but we got a very low rate. We are going to repeat the study in February and make a report by age groups, and we ought then to get a small indication of the cross-section of sickness, as you might call it, at certain age periods. The neighborhood I refer to is a characteristic Russian Jewish neighborhood.

ROYAL MEEKER, United States Commissioner of Labor Statistics: I would like to ask a question about that sickness survey in New York City. I wonder if the low returns mentioned were not partially due to the fact that uniformed health inspectors and police took the census. If we are going to get any accurate statistics, we have to use the most accurate methods of collecting them. Those who took the census were uniformed, and I think that may have scared the people so that they did not get accurate returns.

DR. EMERSON: I believe the census was accurate and correct, as it was all checked by nurses.

B. S. WARREN, Surgeon, United States Public Health Service: In discussing the papers on health insurance I shall confine myself to a consideration of the question of correlation of the administration of medical benefits with other health agencies. The wonderful possibilities of health insurance as a relief measure appeal to me very greatly, but as an officer of the United States Public Health Service I am much more impressed with its possibilities as a measure for the prevention of disease.

Up to the present time sickness insurance systems have failed of the greatest measure of success in preventing disease owing to a lack of proper correlation with other health agencies.

In Germany, where the medical benefits are administered by the "carriers" (which corresponds to the English "approved societies"), there was so much friction with the doctors that the "doctors' strike" resulted and it was only after a long and acrimonious dispute that a compromise known as the Berlin agreement was reached in the

early part of 1914. This agreement was considered at best only a temporary makeshift, but the war broke out soon afterwards and left little time for further consideration of the dispute.

It is hardly necessary to take up your time in pointing out just how unsatisfactory lodge practice is to both doctor and patient. The old careless methods of the "lodge doctor" in prescribing a pill or plaster for all ailments without regard to diagnosis are too well known to need discussion here. The subject, however, should not be left without pointing out that such a system permits but little freedom of choice of physicians; the members are usually limited in their selection to the one or more contract doctors of the society, who are too often doctors willing to underbid others in order to obtain the contracts.

In England, where, prior to the national insurance act, the benefit societies were highly developed, the lodge doctor was a familiar institution. At the time of the act there was such a demand for the abolishment of this method of medical relief that a provision was inserted in the act that the medical benefits be administered by the local government committees and a free choice be permitted from among all the physicians who registered on the panels of the committees. It should be stated here that out of about 25,000 physicians over 20,000 registered on the panels.

The English act, however, has this defect-it places the approved societies at a disadvantage by compelling them to pay cash benefits on certificates signed by physicians selected by the beneficiaries. It must be admitted that the physicians have been entirely too complaisant in signing certificates. Such practice has caused an unfair drain upon the funds and has encouraged malingering. To remedy this evil, some local committees have appointed disinterested physicians to act as referees for doubtful cases. This plan has proven satisfactory in practically all cases where it has been adopted.

In this country some of the large railway companies which operate benefit funds have left the matter of medical treatment to the family physicians but pay no cash benefit except on the certificate of the company surgeon, and they maintain corps of surgeons whose duties are to see and keep in touch with every insured sick person. The statement has been made by one of these companies that they could not maintain the solvency of the funds if they accepted the certificates of the patients' physicians.