the workers to bear the loss of wages more easily, and would distribute more equitably the cost of sickness among the workers, the employers, and the state.

After many conferences, at which all sides of the problem were thoroughly discussed, the American Association for Labor Legislation formulated in the summer of 1914 the following tentative standards which it later followed in the drafting of a health insurance bill for introduction in the state legislatures:1

1. To be effective health insurance should be compulsory, on the basis of joint contributions of employer, employee, and the state.

2. The compulsory insurance should include all wage workers earning less than a given annual sum, where employed with sufficient regularity to make it practicable to compute and collect assessments. Casual and home workers should, as far as practicable, be included within the plan and scope of a compulsory system.

3. There should be a voluntary supplementary system for groups of persons (wage workers or others) who for practical reasons are kept out of the compulsory system.

4. Health insurance should provide for a specified period only, provisionally set at twenty-six weeks (one-half a year), but a system of invalidity insurance should be combined with health insurance so that all disability due to disease will be taken care of in one law, although the funds should be separate.

5. Health insurance on the compulsory plan should be carried by mutual local funds jointly managed by employers and employees under public supervision. In large cities such locals may be organized by trades with a federated bureau for the medical relief. Establishment funds and existing mutual sick funds may be permitted to carry the insurance where their existence does not injure the local funds, but they must be under strict government supervision.

6. Invalidity insurance should be carried by funds covering a larger geographical area comprising the districts of a number of local health insurance funds. The administration of the invalidity fund should be intimately associated with that of the local health funds and on a representative basis.

7. Both health and invalidity insurance should include medical service, supplies, necessary nursing, and hospital care. Such provision should be thoroughly adequate, but its organization may be left to the local societies under strict governmental control.

8. Cash benefits should be provided by both invalidity and health insurance for the insured or his dependents during such disability.

1 American Association for Labor Legislation, Health Insurance; Standards and Tentative Draft of an Act, 1915, pp. 5, 6.

9. It is highly desirable that prevention may be emphasized so that the introduction of a compulsory health and invalidity insurance system shall lead to a campaign of health conservation similar to the safety movement resulting from workmen's compensation.

In addition to the relief value of such a measure, it contains, as indicated in the closing paragraph of the standards, important possibilities for the prevention of illness. After a century of rapid industrial growth and increasing urban population we are just beginning to value as a social factor the sanitation which drains cities, provides pure water and pure milk, and quarantines infectious diseases. We have too long failed to realize that the ill health of the individual, even though he may not be suffering from a contagious disease, is a matter of public concern. Medical care of adults is no less important for a state which values the lives of its citizens than is the medical examination of school children which we have already adopted in the larger cities.

More general medical consultation will reveal unsuspected tendencies which, if allowed to develop, will have as pernicious effects as the adenoids we are so careful to remove from school children. Here, as in England, there are many wage-earners who are unable to afford a doctor's fee. Nor is the dispensary service given in the large cities sufficient to meet the need. A socialized medical service, whereby all who require the services of a physician may have access to the necessary treatment, has been found very effective in some countries. Great Britain's health insurance act has revealed a mass of human suffering, especially among women, which hitherto had received no medical attention. Because of the increased use of doctors, a far larger number of persons have been discovered who need operations and hospital care-persons whose ills previously would have gone without treatment until the suffering had become acute and the chances of recovery had been diminished. Socialized medical service, especially in Germany, has resulted in prophylactic treatment for the individual and in the conservation of national vitality.

Great Britain's health insurance act has been an incentive for undertaking a national campaign against tuberculosis. By means of a sanatorium benefit for every insured worker suffering from this disease, more adequate treatment is being

provided. In Germany, particularly, the health insurance law has been an important factor in the anti-tuberculosis campaign. German authorities even attribute "the progress which has been made in the crusade against tuberculosis more to the industrial insurance laws than to any other cause, owing to the fact that those laws have placed within the reach of the working classes resources of healing which were never dreamt of before."1

Furthermore, the necessity of spending money on preventable disease is in itself a stimulus to prevention. Various English bodies have been aroused by this factor to a keen interest in the relation between tuberculosis and housing. The financial pressure on "approved societies" is a direct inducement to demand thorough inspection of dwellings and workplaces, especially since the delinquent authority can be made to pay the cost of the sickness produced by the poor sanitary conditions which it has allowed to exist.

It is also possible, as is done in Germany, to levy a higher premium upon the industry or particular establishment in which the sickness rate is higher than normal. This is a means tending to persuade the employer of the economy of factory sanitation which will improve the health of the worker and thereby reduce his insurance premium. It is the same inducement of low insurance premiums for workmen's compensation which is partially responsible for the "Safety first" movement and the installation of safety appliances. Without a compulsory health insurance system, the economy of health preservation cannot be made an effective lever for reform.

3. OLD AGE AND INVALIDITY INSURANCE

The rapid development of industry has, among its other results, placed emphasis on the individual's physical vigor and wage-earning capacity. It has deprived old age of the esteem bestowed upon it under more primitive patriarchal conditions, and after a life of productive toil it relegates to the background the aged or incapacitated man as a useless, uneconomic

1 Dawson, Social Insurance in Germany, p. 202.

factor. Failing health, inability to find employment, lack of means, often absence of friends willing or able to help him -such is the prospect which confronts, in the great majority of cases, the aged worker.

(1) Unassisted Old Age Insurance

In response to the gravity of this situation three main measures of relief have been developed: charity, saving, and insurance. Charity has been known since ancient times, and no doubt has relieved a deal of destitution. But the modern opinion is that charity, both private and public, is insufficient in amount and unsatisfactory in quality; that it exercises a degrading effect upon the recipient and is repugnant to the self-respecting person. The serious difficulties in the way of saving are also well known. The low standard of wages seldom, if ever, allows any surplus; most often the immediate demands outweigh the arguments in favor of saving. Besides, the very remoteness of old age and the uncertainty of attaining it discourage many people from making preparation for the future at the expense of the present. In this problem, as in that of provision for illness, the collective process of insurance is considered much more satisfactory than the individualistic_method of savings. Professor Seager has said that "for every wage-earner to attempt to save enough to provide for his old age is needlessly costly. The intelligent course for him is to combine with other w wage-earners to accumulate a common fund out of which old age annuities may be paid to those who live long enough to need them."1

The development of oid age and invalidity insurance is similar to that of health insurance. The first stage in the movement was marked by optional unassisted insurance, which is still furnished by some fraternal societies, trade unions, establishment funds, and insurance companies. However, the number of fraternal societies and trade unions, either here or abroad, which undertake the complicated business of old age and invalidity insurance is small. In many

1 Henry R. Seager, Social Insurance, 1910, pp. 118, 119.

states of this country fraternal societies are prohibited from dealing in it. Only forty-two out of 182 general or national fraternal benefit societies in the United States promise old age benefits, and these usually do not begin until the age of seventy has been reached.1 As to American trade unions, out of the approximately 110 national organizations four are known to pay a superannuation benefit. These are the International Typographical Union, the Granite Cutters' International Association, the Amalgamated Society of Carpenters and Joiners, and the Amalgamated Society of Engineers, the last two being branches of English unions. In a few other unions the introduction of this form of insurance is being considered, and in some old age benefits are paid by individual locals. Nineteen unions, the majority of which consist of transportation workers, pay a permanent disability benefit. Business concerns furnishing old age insurance for their employees are also rare, especially in this country, as are those granting straight old age pensions. Insurance companies do a considerable old age annuity business in Europe, chiefly among the middle class; in the United States, on the contrary, commercial insurance for old age is little known.

2

(2) Assisted State Plans

Obviously, voluntary unassisted old age insurance reaches only a small part of the wage-earners. As a consequence, as in the other branches of social insurance, it came to be considered the duty of the state to assist its aged citizens, and the principle of state insurance, sometimes aided by subventions, was devised.

This form of voluntary old age insurance is known in France, Belgium, England, Italy, and Spain, and in America in the states of Massachusetts and Wisconsin, and in Canada. France, Belgium, Italy, and Spain grant subventions in the form of a substantial rate of interest, and to certain classes

1 Lee W. Squier, Old Age Dependency in the United States, 1912, p. 67. 2 United States Commissioner of Labor, Twenty-third Annual Report, "Workmen's Insurance and Benefit Funds in the United States," 1908, p. 31.