Medical Care Before the Welfare State, 1900-1930
On the face of it, a historical study of fraternal societies seems to be a subject fit only for connoisseurs of the arcane. Few Americans these days come into contact with such groups. When many of us hear the word lodge, we think of it as a place where television characters from our youth, such as Ralph Kramden (of the Loyal Order of Raccoons) and Fred Flintstone (of the Loyal Order of Water Buffalos), escaped from their more sensible wives to engage in childish hijinks—parading around with silly hats and mouthing pretentious rituals.
There was a time, however, when fraternal societies could not be so easily dismissed. Before the rise of the welfare state, they were rivaled only by churches as organizational providers of social welfare. By conservative estimates eighteen million American men and women were members in 1920 at least three out of every ten adult males. While fraternal societies differed in ethnicity, class, and gender, most shared a common set of characteristics. In general, this included a decentralized lodge system, some sort of ritual, and the payment of cash benefits in times of sickness and death.
By the turn of the century, an increasing number of societies began to add treatment by a doctor to their menu of services. This arrangement was known as lodge practice. It involved a simple contract under which a physician provided care in exchange for an annual salary determined by the size of lodge membership. To qualify, a prospective lodge doctor had to win an election by the members. Generally lodge practice plans did not extend beyond basic primary care and minor surgery, although a few provided hospitalization.
Lodge practice became particularly extensive in urban and industrial centers. In 1915, for example, Dr. S.S. Goldwater, Health Commissioner of New York City, went so far as to assert that in many communities it had become “the chosen or established method of dealing with sickness among the relatively poor.” In the Lower East Side of New York City, he noted, 500 physicians catered to Jewish societies alone. Among blacks in New Orleans there were over 600 fraternal societies with lodge practice during the 1920s.
Nationally, the two leading providers of lodge practice among native whites were the Foresters and the Fraternal Order of Eagles. By 1910, both organizations had over 2,000 doctors under contract to look after the medical needs of about 600,000 members. Yet, aside from the common thread of lodge practice, the Foresters and Eagles were actually quite unalike as fraternal societies.
The Foresters
The Foresters traced their origins directly to the Ancient Order of Foresters, a British organization. The ritual drew inspiration from Robin Hood and his legendary adventures in Sherwood Forest. In keeping with the medieval motif, the lodges were called “courts” and the supreme leader a “chief ranger.” Both women and men could join (although in separate courts) and the only tests for membership were belief in a supreme being and good moral character.
Foresters were quintessential internationalists. In an age of self-conscious Anglo-Saxon exclusivity, they were notable among fraternal societies for seeking converts not only in Europe but also in Asia. The chief ranger for over two decades was a Dr. Oronhyatekha, a Canadian Mohawk. Equally remarkable for the time, his ancestry was not a cause of embarrassment for the members; in fact, they wore it as a badge of distinction. One member boasted that “There is not a Forester in the wide world but knows that this full-blooded Indian chief is the one man to whom the Order should be thankful for its wonderful growth.”
The Eagles
While the Foresters eschewed nationalism, their leading rival for lodge practice, the Fraternal Order of Eagles was almost a caricature of apple-pie Americanism. The Eagles opened their first lodge in Seattle, Washington, in 1898. The members embraced a fun-loving and informal style quite unlike more solemn co-fraternalists, such as the Free Masons. The aeries (as Eagles called their lodges), with their well-stocked bars, often served double duty as local community centers. This freewheeling behavior earned the Eagles an unsavory reputation in some quarters. In 1910, McClure’s Magazine characterized the group as “a great national organization of sporting men, bartenders, politicians, thieves, and professional criminals.” The Eagles later refurbished this unwholesome image somewhat by launching a highly visible, and ultimately successful, campaign for the proclamation of Mother’s Day.
Less than ten years after the Eagles had been founded, they became noted (notorious in medical society circles) for engaging in lodge practice. For one dollar a year, a member and immediate family could receive basic medical services (including minor surgery). This fee did not pay for treatment for obstetrics, venereal disease, and “any sickness or injury caused or brought about by the use of intoxicating liquors, opiates or by any immoral conduct.”
Ladies Friends of Faith
Unfortunately, primary data from individual societies with lodge practice is in very short supply. Nevertheless, some records survive which can shed light on the subject. Particularly helpful is a minute-book from the Ladies Friends of Faith Benevolent Association, covering the period from August 1914 through September 1916. It was a black female society of about 170 members which operated in New Orleans during the early twentieth century.
The Ladies Friends of Faith was not exceptional, at least within the broad context of New Orleans. It was only one of numerous such societies which offered lodge practice to blacks in the city. Among these were local affiliates of two prominent national organizations, the Eastern Star and the Household of Ruth. Much more common, however, were home-grown societies such as the Female Union Band, Young Men of Inseparable Friends, Francs Amis, Holy Ghost, and the United Sons and Daughters. A simple reading of 134 organizational names from a list assembled in 1937 indicates that no less than 40 catered primarily to females.
In terms of organizational structure and benefits, the Ladies Friends of Faith also fit the general local pattern. The rank-and-file voted in annual elections to choose a “society” druggist, doctor, and undertaker who provided services at a low flat rate. Those taken sick collected two dollars a week if they saw the lodge doctor and three dollars if they did not. To guard against false claims for cash benefits and to provide companionship, a visiting committee sat at bedside with the recipient. Those members derelict in these duties had to pay a one-dollar fine.
In this two-year period, the minute-book evidences great activity. One hundred and thirteen individuals (slightly over half the membership) collected sick benefits. Of these, 70 used the lodge doctor at least once; several a dozen times or more. Almost all these applicants obtained cash payments and medical service (including free medicine) without eliciting complaints from the other members.
This does not mean that the deliberation process of the Ladies Friends of Faith was without controversy. Most notably there was a persistent need to grapple with appeals from individuals who had fallen in arrears. At nearly every meeting, the society heard at least one plea from a member unable to pay because of unemployment or poor health. One of the most desperate of these concerned a woman who was “out of Doors, and had no money.” In such cases, the society was generally ready to extend help. It allowed 24 members extra time to pay off their debts while it passed the hat for ten others. Not once did the Ladies Friends of Faith reject any of these appeals outright. Such liberality did not translate into open season on the lodge’s treasury, however. Those delinquents who failed to explain their “unfinancial” status were readily dropped from the rolls.
Regardless of religious, ethnic, or political orientation, all fraternal societies, to the extent they relied on lodge practice, faced a similar set of obstacles. Without a doubt, the most serious was the organized opposition of doctors. By the first decade of the twentieth century, the spread of what became known to critics as the lodge practice evil elicited almost universal condemnation among medical societies.
At its core, this opposition represented fear for the future survival of the dominant fee-for- service remuneration. Writing in the Wisconsin Journal of Medicine, Dr. W. F. Zierath of Sheboygan, Wisconsin, put the matter succinctly when he chided certain fellow members of the profession for bowing so readily to “the keen business instinct of the laity” who have “discovered in contract practice a scheme to obtain medical services for practically nothing . . . they are orga nizing societies by the score with that feature as the excuse for their existence.” Once doctors allowed themselves to be placed on a fixed payment system, he warned, loss of both income and independence would soon follow. The profession would then become tainted and demoralized by every doctor’s cutthroat and undignified scramble to sell to the lowest bidder. Another opponent predicted that lodge practice, if not stopped, would depress fees to levels “comparable to those of the bootblack and peanut vendor.”
Lodge elections were depicted as carnivals of corruption in which victory went to those doctors best able to ingratiate themselves with key players in the leadership through extravagant promises or outright bribery. Even when outright corruption did not occur, the critics portrayed the election campaign as dominated by unseemly wire-pulling and backslapping. According to Dr. Zierath, success of a candidate depended upon “the handshaking, the button-holing, the treating to cigars and drinks in public houses.”
According to these critics, however, lodge practice was not only bad for doctors, but it also harmed the patient. While they conceded that the fees were low, they warned that the service given in return was shabby. Along these lines, a leading professional journal condemned lodge practice as a vain attempt by the patient to get “something for nothing.”
Who Benefited?
Lodge practice, in my view, merits a far more favorable assessment than it received either from contemporary critics or more recent historians. At first blush, such a contention would seem impossible to defend. Most of the surviving sources on which the historian must rely already have turned in a ringing verdict of guilty. This research problem is not fatal, however. Ironically, the strident manifestos published in the medical journals contain a wealth of information which can cast a positive light on lodge practice. With great profit, these professional critiques can be supplemented and compared to the still extant defenses written by doctors and leaders of fraternal societies.
The most important beneficiary of lodge practice was, of course, the patient of modest means. He or she was able to obtain the care of a doctor for about two dollars a year roughly equivalent to a day’s wage for a laborer. If translated into 1994 dollars, this annual fee would be equivalent to about 14 dollars, the hourly wage of some construction workers today!
The remuneration paid to the lodge doctor was a far cry from the higher fee schedules favored by the profession. A local medical society in Pennsylvania was typical in setting for its members the following minimum fees: one dollar per physical examination, surgical dressing, and housecall (daytime) and two dollars (nighttime). Such prices, at least for continual service, would have been out of reach for many poor Americans.
Why were the lodges able to charge such low fees? The answer to this question lies with several organizational strengths peculiar to the fraternal structure itself. The fact that lodges could entice doctors with a large and stable market left them well positioned, as one opponent put it, to purchase medical services at wholesale and sell at retail.
Also exerting downward pressure on fees were lodge elections. While the election process was not without flaws, there is also ample evidence from both supporters and opponents that, on balance, it served members well. It gave patients an opportunity once a year to compare notes on the medical records of both the challenger and incumbent. John C. McManemin, the Past Worthy President of the Eagles, maintained that as “the members have the right of franchise in electing the lodge physician, so have they in deposing him, and it therefore results that unless the physician so selected, attends to the duties devolving upon him he is quickly brought to account.” From a very different perspective, a leading opponent of lodge practice complained that during campaigns “colleagues and rival applicants are roundly ‘knocked’ and their mistakes and capabilities held up to public ridicule and censure.”
Quality of Service
Closer inspection of the medical journals also gives some cause to be skeptical of blanket claims that lodges heedlessly sacrificed quality to elect the candidate bidding the lowest fee. The contrary, in fact, occurred in a campaign described by lodge-practice adversary Dr. George S. Mathews of Rhode Island:
. . . in one lodge two members in good standing in the State Medical Society openly in lodge meeting underbid [each other]. One volunteered his services at $2 a head. The other dropped his price to $1.75. The first bidder then acceded to this price with medicines furnished. This oc-casioned a drop in bidder No. 2 in his price to include medicine and minor surgery. To the vast credit of the lodge neither bid was accepted but a non-bidder was given the job at $2.
Even the detractors, while generally disdainful of the quality of care provided, acknowledged that fraternal societies attracted some doctors of ability and high training. In Dr. Goldwater’s opinion, for example, there were “many competent medical men and between the slip-shod service of the poor kind of dispensary, and the painstaking care of the conscientious lodge doctor, the choice easily lies with the latter.” It is worthy of note that the hack often inspired less contempt than the physician with a lucrative private practice who took a lodge contract on the side. One leading critic excoriated such individuals as “inordinately selfish and avaricious men who have no neighbors in the profession, for they are not Samaritans by practice.”
Proprietary Medical Schools
Also misleading were efforts to dismiss the abilities of lodge doctors by citing their low level of medical education. For many opposed to the system, it was merely sufficient to note that these doctors graduated disproportionately from the ranks of the proprietary medical schools. While as a description of reality this was probably accurate, it fails as an indictment. To understand why, a bit of background about proprietary education might be helpful.
These schools had two salient features. First, they were owned by doctors in regular practice and second, unlike the endowed university, they subsisted entirely on tuition. The owners earned income both from tuition received in exchange for delivering lectures and from sometimes lucrative referrals tendered by grateful graduates. The students often came from modest back grounds and thus lacked both the contacts and financial pull enjoyed by many of their counterparts in the universities. The alumni of these proprietary schools would have ample incentives to be attracted to lodge practice. For a recent graduate especially, a contract with a fraternal society might be the only means available to obtain the necessary financing and community contacts needed to build up a practice.
To call these doctors quacks, however, as many critics did, would be a misnomer, at least in the strict meaning of the term. Like every other aspiring doctor, they needed to receive state certification to practice. By no means was this pro forma. Since the 1880s and 1890s, the requirements had become increasingly stringent and failure rates were high. In short, the lodge doctor may not always have been top-of-the-line but he or she had at least rudimentary training.
As the purchaser of these services, the fraternal society also had incentives to maintain the quality of care. An incompetent or arbitrary doctor could prove fatal to actuarial soundness. Moreover, if fraternal advertisements are any indication, prospective members were leery of organizations with high mortality rates. The publicity for the Foresters repeatedly contrasted the death rate of its members (6 per 1,000) with that of the same age group in the general population (9 per 1,000). It credited this low mortality to “Sherlock-Holmes-like acuteness in the detection of bad risks” exhibited by the doctors attached to its courts. This boast was more than hyperbole. In the first decade of the twentieth century, the doctors of the Foresters annually rejected between ten and twenty percent of all initiates.
Additionally to ensure quality of care lodges often imposed specific sanctions, in the form of fines, for doctors who neglected their duties. Among the possible infractions were failure to report at meetings, fraudulent approval of sick claims, and refusal to respond to a patient’s housecall. For the latter violation, for example, both the Eagles and Foresters authorized a lodge to hire a substitute from the open market and then deduct the charges from the salary of the delinquent lodge doctor.
An important consequence of lodge practice for the patient was to facilitate habits of assertiveness. The members who used these services anticipated by several decades the active patient now very much in vogue. Many physicians, obviously unaccustomed to such treatment, denounced the willingness of members to quibble about fees and diagnosis. One doctor blamed excessive and unnecessary housecalls for engendering fears in the doctor “that he will lose his position if he fails to answer every call regardless of circumstances and his knowledge of the fact that he is being imposed on constantly by members who abuse their privileges.”
For the patient, if not always the doctor, lodge practice had the additional virtue of affording accessible preventive care. Again, one need look no further for evidence than the repeated accusations in the professional journals that doctors were being pestered with trivial ailments. According to Dr. Zierath, the patient called on the lodge doctor at all hours of the night “to see cases repeatedly where a physician would not be called, were the regular fee to apply. One of the children in a family has abdominal pain, and the anxious mother promptly conjectures that it is appendicitis” when it was nothing more “than too much indulgence in mince pie. But it looks stylish to have the doctor’s rig standing in front of house and excites the curiosity and envy of the neighbors, therefore the ‘free’ doctor is summoned.”
For fraternal societies, by contrast, the ability to readily call on the doctor for any complaint was a major selling point. Lodge practice, wrote a leader of the Eagles, “accords perfectly with the modern theory of the prevention of disease . . . Many of the poorer members, under other circumstances might delay in calling a doctor until the disease made considerable headway.”
Lodge practice opened up rare opportunities for many working-class Americans to compare and experiment and empowered them with the necessary economic clout to break free from the confining view that health care was merely a generic good. It gave patients the wherewithal to use medical services more as a varied menu. of choices, each adjustable to suit the particular need at hand.
The discernment of lodge patients was exemplified by their selective patronization of medical services. They may have readily turned to their lodge doctor for prevention, for example, but many looked elsewhere for a cure. On this note, an exhaustive study of blacks in New Orleans, who were members of fraternal societies during the 1930s, found that while 56 percent relied exclusively on the doctor hired by their lodge, the rest also hired private physicians in some cases. A member of one of these societies expressed a typical view when he commented, “Well, I think there is nothing better than a society for when you’re sick they give you the best possible attention, but if I were real sick I’d prefer calling a doctor not connected with a society, so that I could get the best of attention. Society doctors are too busy to handle extreme illnesses.”
Decline of Lodge Practice
Even before the Depression, lodge practice had begun to fall into a state of decline. The pressure exerted by the leaders of organized medicine hastened the demise. By the 1910s, doctors had launched an all-out war against lodge practice. Throughout the country, medical associations imposed a range of sanctions against lodge doctors, including expulsion from the association and denial of hospital facilities. In certain instances, campaigns were organized to deny patient care, even in emergencies, to members of offending lodges. Most commentary from both sides of this conflict indicates that these sanctions were highly effective. In any case, by the end of the 1930s, the once vibrant health care alternative of lodge practice, which less than two decades before had inspired trepidation throughout the medical establishment, had virtually disappeared.