Beatrix Rebecca Hoffman’s The Wages
of Sickness focuses on New York’s first proposal for government sponsored
health insurance. She claims that an organized and unified opposition, composed
of medical professionals, employers, commercial insurance companies and
mainstream labor, used the rhetoric of Americanism to defeat divided proposal
supporters. Supporters of the proposal were labor and women’s groups that often
had to face divisive opinion from other labor and women’s groups. Hoffman
argues that the failure of this early proposal for compulsory health insurance
was a “formative moment” for America in that it contributed to the “making of a limited welfare state, …
and configuration of interest-group power that would resist universal health
coverage for the rest of the century.”[1]
Although Hoffman successfully demonstrates how the opposition defeated
compulsory health insurance, she is lackluster in her broader argument that the
defeat was a formative moment. Most of her book is spent discussing the defeat
of the compulsory health insurance in the early 20th century, while
the only epilogue tries to extend to the present. That being said, The Wages of Sickness is a good
precursor for Hoffman’s next book, Health
Care for Some: Rights and Rationing in the US Since 1930.
Hoffman starts off by explaining
the health care situation prior to the proposal of compulsory health insurance.
She describes the mixture of various health services offered as a “patchwork of
protection” restrictive in their application.[2]
This “patchwork of protection” consisted of fraternal societies, trade unions,
employer sickness plans, commercial health and life insurance plans, and
charity medicine. A combination of these services served as New York’s health
care system and was inadequate in protecting all of the city’s workers.
The second chapter concentrates
on the creation of the proposal for compulsory health insurance and its
organizational sponsor, the American Association for Labor Legislation (AALL). Hoffman
states that the AALL defined itself as a bureau of “experts” with the aim of
worker protection.[3]
These “experts,” drawing from successful European models, proposed compulsory
health insurance as a means to conserve the value of the worker. Their model
legislation of compulsory health insurance was far from ideal. Hoffman notes
that the legislation was designed at the state level for workers only and
excluded the nonworking poor, middle class, and blacks.[4]
She next highlights a major theme of the book, the AALL’s failure to garner
significant support and its underestimation of the opposition. The
organization’s failures partly were because of their “expert” and third party
stance that led them to exclude workers and employers from discussions.[5]
Because the AALL previously passed reforms without significant resistance, they
naïvely expected that the workers and employers would support them. Thus the
opposition at the 1917 New York State Judiciary Committee hearings astonished
the AALL.[6]
Hoffman next goes on to discuss the development of the opposition against
compulsory health insurance.
The opposition against
compulsory health insurance came from mainstream labor, medical professionals,
employers, and commercial insurance companies. Each group opposed compulsory
health insurance for their own self-serving reasons. Mainstream labor, under
the leadership of Samuel Gompers of the American Federation of Labor (AFL), opposed
compulsory health insurance because they believed that the plan would undermine
trade union benefits and stop the battle for higher wages.[7]
Medical professionals (Major organization being the American Medical
Association also known as AMA) feared that compulsory health insurance plans
would decrease their incomes. Employers were in a similar line of thought and
believed that premiums for the health insurance would eat into their profits.
Insurance companies saw compulsory health insurance as the death of their
health and life insurance market. All groups opposed the unprecedented reach of
the government into the sphere of private interest. Such motivations were a clear indication of
the self-preserving nature of these entities and were not effective rallying
cries for public support.
Various more palatable
arguments were used by the entities to undermine the push for compulsory health
insurance. According to Hoffman, a major charge against compulsory health
insurance was that it was “socialistic” and “un-American.”[8]
Opponents decried how the health insurance proposal took away from “American
freedoms” and had foreign, European origins. Mainstream labor could point at the
mandatory nature of premiums as state coercion taking away from workers wages. Physicians
could target compulsory health insurance as an attack on the autonomy of the private
practice. Employers and commercial insurance companies could aim at the
government intervention into the private business domain as socialistic. These
charges were not without hard “evidence.” Critical to the oppositions’
arguments were the different organizations that provided the ammunition against
compulsory health care. The National Civic Federation (NCF) and National
Industrial Conference Board (NICB) were two organizations that focused on labor
studies, both abroad and at home. Reports from both these organizations used biased
statistical evidence that lamented the detriments of the European insurance
program and downplayed the losses of worker sickness.[9]
Another organization, the Associated Manufacturers and Merchants of New York State
(AMM), was more direct in its opposition to compulsory health insurance. As a
representative of employer interests, the AMM opposed all forms of labor
legislation as “obnoxious, impractical and wholly unnecessary.”[10]
All three organizations, NCF, NICB, and AMM cooperated in their opposition to
the health insurance bill.
Hoffman pays special
attention to five opposition individuals: Samuel Gompers, Frederick Ludwig
Hoffman, Mark Daly, Florence Kelley and Thaddeus Sweet.[11]
Gompers was already a striking figure in Progressive American labor history,
but this time he appears as an antagonist. Originally part of the AALL, he left
because of what he viewed as the “socialistic” nature of compulsory health
insurance. Next is Hoffman’s study of Frederick Ludwig Hoffman who she deems as
“the nation’s single most active and influential opponent of compulsory health
insurance.”[12]
As vice president of Prudential Insurance Company and a member of the NCF,
Frederick Hoffman lobbied against the AALL bill in secret, pretending that
“Prudential was simply a detached observer.”[13]
In reality, he worked behind the scenes to undermine the AALL compulsory
insurance bill. In fact, Gompers was involved in a backroom dealing with
Fredrick Hoffman on November 1920. At the meeting, Gompers asked “an insurance
executive to represent the labor point of view.”[14]
Mark Daly participated in this subterfuge as spokesman for the AMM. He
regularly attended NCF Executive Committee meetings and later cooperated with
the New York League for Americanism (NYLA), forming an insurance
company-manufacturer cooperation that would successfully oppose compulsory
health insurance.[15]
In contrast to the rest of the group, Florence Kelly is portrayed by Hoffman as
a misguided reformer. Kelly opposed the AALL’s cash maternity benefits because
she believed that such benefits would depress the wages of single women and
force pregnant women to work.[16]
The final boss of the opposition was Thaddeus Sweet, a Republican speaker and
upstate manufacturer representing Oswego County. As leader of the assembly
Rules Committee, he had the power to prevent Progressive legislation from passing
to vote. His strong grip on the New York State government was vital in
preventing a vote on compulsory health insurance from 1919 to 1920.
In comparison to a
strong opposition was a divided support for the compulsory health insurance
bill. The split among the labor and women’s groups contributed to the bill’s
defeat. As noted earlier Gompers and the AFL opposed compulsory health
insurance. However, the AFL’s word was not the final say for all labor groups.
The New York State Federation of Labor (NYSFL), the International Typographical
Union and other local trade unions supported the bill despite the AFL’s
opposition stance. For women’s groups the same story unfolded. Florence Kelly
and the Women’s League for Equal Opportunity (LEO) opposed compulsory health
care as a detriment to workers wages and freedoms. Like with the AFL, Kelly and
LEO were opposed by other women’s groups that supported the bill. The two most
notable support groups were the Women’s Trade Union League (WTUL) and the
International Ladies’ Garment Workers’ Union (ILGWU). Hoffman specifically
concentrates on ILGWU organizer, Pauline Newman, as a vocal supporter of the compulsory
health insurance. Newman attacked Kelly’s stance as short sighted and divorced
from the realities of workingwomen. She then trained her sights upon the AFL
deriding the organization for clinging “to the old idea of getting higher wages
and allowing corporations to take it back in the higher prices of the
necessities of life.”[17]
However powerful of a speaker Newman was, the divisions within labor had
significantly weakened the AALL’s base of support. Workers were thrown into
confusion as their leaders bickered over the impact of compulsory health
insurance.
The Americanism spewed
forth by the opposition was used to highlight the socialistic and Germanic
origins of compulsory health insurance while at the same time emphasizing
American exceptionalism. This extreme patriotism may have seemed absurd, but in
the middle of World War I and the accompanying Red Scare these arguments were
extremely persuasive since the public was amidst a war fever. The AALL dismissed
the “diverse and often contradictory arguments,” as “highly irrational.”[18]
However, rationality meant little in the terms of political discourse. The AALL
underestimated the weight of patriotic discourse on political influence.
Hoffman ties up her book
with the 1920 defeat of the compulsory health insurance bill and a quick
history of other health care reform attempts. All the factors: united
opposition, divided labor support, and Americanistic rhetoric combined to crush
the bill’s legislation. The opposition with its organizational network and
political hold effectively blocked any efforts to pass the bill through the
assembly. Labor, which was supposed to have universally supported the bill
because its benefits, ended up divided. Germany’s defeat in World War I
demonstrated the supposed failure of the “Bismarckian welfare state” and the
boosted Americanism.[19]
In the end the tide was too strong. The bill’s proponents gave up the battle
after being worn down by years of attacks on the “un-American” character of
compulsory health insurance.[20]
The patchwork system of health care remains to this day with reform attempts
from other presidents: Roosevelt, Truman, Kennedy, Nixon, and Clinton, all
failing as well.
Wages of Sickness does a successful job presenting the opposition’s
victorious strategy and the division in labor. Quotes from backlogs and private
messages help to generate a view of the opposition’s conversation. These quotes
are backed up with details from the works of other historians and photographs. Gompers’
contradictory stance on compulsory health insurance is demonstrated in his
secret dealing with Fredrick Hoffman. The NCF and NICB are revealed to be far
from unbiased, objective sources of information. Manufacturers are clearly
colluding as shown through the AMM and the organization’s role in the NYLA. Sweet’s
role establishes the link between legislation and business. NYSFL’s break from
the AFL’s stance indicates a major rift between labor unions. Newman’s battle with
Kelly also depicts the division within labor. The opposition of mainstream
labor, employers, medical professionals, and private insurance companies ensured
the defeat of compulsory health care.
Beatrix Hoffman’s book
undeniably leans left in its criticism of the opponents against compulsory
health care insurance. Gompers is depicted as a traitor to labor through his
dealing with Fredrick Hoffman. Fredrick Hoffman is portrayed as a behind the
scene schemer that outright lies to the AALL. Mark Daly and Thaddeus Sweet are
illustrated as self-serving businessmen. Kelly is presented as a misinformed
speaker. In contrast, praise is heaped on Pauline Newman for her sharp retorts
against the opposition. Hoffman even ends the book with a quote from her.[21]
Hoffman comes up short when
trying to prove that the early 20th century push for compulsory
health insurance was a formative moment for America that led to a fragmented
healthcare system and a opposition that would continue to resist for the rest
of the century. The fragmented healthcare system was already in place prior to
the drive for compulsory health insurance. Failure in 1920 did nothing to
change the patchwork healthcare system. In terms of the opposition, the AFL
split from the opposition early on after 1920. Hoffman notes the AFL’s
defection, but smoothly states that, “the major opponents of universal health
insurance remained the same.”[22]
The rest opposition did continue to oppose health insurance, but the book does
not go into much detail over how the coalition against universal health
insurance stays united. Instead a quick history from post-1920 to the Clinton
administration is given and the opponents of the universal health care are
assumed to be the same. What is emphasized is that the actions taken by
universal health care opponents follow a pattern of Americanism.
Wages of Sickness contributes to the
historiography for proponents of universal health care. Hoffman intends to
prove that “what did not happen shaped what did” and that American resistance
to universal health care can be overcome.[23]
Hoffman’s aim was to encourage health care reform with the final goal of
universal health care in mind. She pays close attention to why the health care
reforms of the early 20th century failed in order to make sure
future reformers will not fall into the same potholes. Previous historians
solely focused on the AMA as the antagonist to health care reform. For her the
AMA was just a segment of the opposition. The real opponents of universal
health care are those who stand to lose economically, the employers, private
insurance companies, and even labor. Her study of the failed push for New York
compulsory health insurance provides a perfect segues into her next book, Health Care for Some.
Beatrix
Hoffman’s Health Care for Some
broadens the examination of health care to a new time period, the Great
Depression and beyond. Instead of analyzing one push for healthcare reform like
in Wages of Sickness, she looks at
the trend of healthcare coverage. The term rationing is critical to her
analysis of health care trends. Hoffman’s definition of rationing, “control and
limitation of the consumption of a product or service,” is applied to the US
system of health insurance.[24]
According to her, there are two types of rationing in US healthcare: explicit
and implicit. Explicit ration denies care according to an official set of rules
written out. Implicit rationing is the denial of care through the problems of
life such as the ability to pay. She argues “US-style rationing, along with the
lack of universal health care rights for US citizens, has contributed to the
comparatively high cost of health care.”[25]
Her plan is to demonstrate a US pattern of “rationing” healthcare throughout
the past 80 years, breaking down the analysis into four chronological sections:
Great Depression, WWII and the postwar, 15 years following the passage of
Medicare and Medicaid, and 30 years since 1980. Hoffman’s argument is solid when
discussing the patterns of healthcare rationing throughout US history and how
continued US rationing has contributed to the high cost of health care. However,
her findings contradict with her concluding stance on the Patient Protection
and Affordable Care Act and her earlier book, Wages of Sickness.
The
prologue, Rights and Rationing Before 1930, investigates early health care
denial via occupation and race using information from Hoffman’s Wages of Sickness to draw out the
beginnings of healthcare reforms. First, she describes how medical care in early
colonial America was a local responsibility. Hoffman then proceeds to discuss
the issue of health care being a right. Both the US Declaration of Independence
and the US Constitution made no mention of a right to health.[26]
Next, she brings up the NY battle for compulsory health insurance from Wages of Sickness, highlighting the
failure of the bill. Despite the defeat of compulsory health insurance, the issue
of national health care remains alive because of systematic healthcare problems
that place burden on middle class families.
In
part 1: The Struggle for Health Care in the Great Depression, Hoffman discusses
how the severity of the depression forced the issue of health insurance back
into the spotlight. The sudden large influx of former middle class Americans to
the poorly coordinated public-private health care system demonstrated the
inadequacy of standard health services. People who originally could afford private
health services found themselves at the mercy of the bureaucratic mess present
in public hospitals. Public county hospitals, already strained to the limit,
were also hit by financial difficulties from patient unable to pay for health
services.[27]
Hoffman asserts that the rationing was even more pronounced now that health
care system was burdened with newly poor patients. Health services were rationed
based on medical condition, geographic location, race, and time. Explicit
rationing came in the form of specialty clinics that only serviced patients
with specific conditions such as tuberculosis or sexual transmitted diseases. Those
with the “incorrect” illness were turned away.[28]
Another form of explicit rationing was race. Clinics refused or had quotas for
African American patients.[29]
Implicit rationing came in the form of long distances to and from health
services as well as time limits. Impoverished patients could not afford
transportation and had to walk the entire distance. Time served as implicit
rationing by restricting the possible number of treated patients as well as
limiting patient medical treatments. Patients had to wait in long lines for
hours unsure of whether or not they would receive medical treatment before the
facilities’ closing time.[30]
Those that were unable to see the doctor had to revisit repeatedly since many
clinics operated on a first come first serve basis. These conditions were part
of the patchwork of the US public-private healthcare system already entrenched
within the nation. However, the Great Depression exhausted the healthcare
system as medical establishments had to deal with the twin combination of heavy
patient loads and lack of funds.
The
dire situation pushed health institutions to demand for state and federal aid. According
to Hoffman, these demands for monetary reimbursement were not argued “on the
basis of a right of health care for patients,” but rather on “the right of
doctors, clinics, and hospitals to be reimbursed for care they had given
without compensation.”[31]
In simpler words, the medical establishment from hospitals to doctors wanted
funding because they were going through tough times. The catch was that they
wanted funding from state and federal coffers without strings attached. Although welfare and clinic leaders were
disappointed by lack of federal funds in the 1930s, the hospital industry
succeeded in gaining state funds. The issue of federal funding would not follow
till much later.
President
Franklin D. Roosevelt (FDR) avoided healthcare because he wanted to avoid
antagonizing the AMA.[32]
FDR’s failure to address healthcare reform resulted in the precedent of pushing
forward hospitals legislation as an alternative to healthcare reform.[33]
Still the issue of paying for healthcare could not be ignored. Although the AMA
continued to oppose group practice and health insurance, the mounting costs of
treatments meant that a new payment system was needed. Thus in 1938, Blue Cross
was born. Hoffman agrees that Blue Cross was “a success.”[34]
However, she adds that one major limitation of the Blue Cross plans was that
they covered only hospital fees, not doctors’ fees. The discontent from the
partial payment plans pushed forward Blue Shield, as an insurance plan for
doctors’ fees. However, both Blue Cross and Blue Shield were limited to hospital
service and did not cover primary physician office visits. Worse, the presence
of the hospital insurance plans provided arguments against national health
insurance. Private health care solutions thus became the new standard to
dealing with medical payment plans.[35]
For
part 2: Prosperity and Exclusion, Hoffman details how the postwar era lead to
the rise of the medical hospital and private insurance industry. Hoffman links
the rise of hospitals to the Hill-Burton Act of 1946. The act gave federal
funds to hospitals without any oversight.[36]
Thus, the issue of federal funding returned once again, only this time
hospitals succeeded in gaining funds without any strings attached. The
increasing number of hospitals was reasoned as a method of providing more
health care to Americans.[37]
The problem was that despite increasing the number of hospitals, groups of
patients were continually being denied access.
Hoffman describes this denial of care as rationed healthcare based on race
and the ability to pay. Although the Hill-Burton act specified that hospitals
were to provide a “reasonable volume of services to persons unable to pay,” most
hospitals ignored the specification.[38]
Hospitals had the financial incentive to lower their free care since the law
also required hospitals to be self-supporting after federal funding. Thus,
hospitals denied care to groups that it viewed as financially loathsome. In the
south, new hospitals fit into the Jim Crow System through segregation of
facilities.[39]
Black and White patients were kept separate from each other and given different
hospital wings.[40]
These denials of treatment based on race and ability to pay even extended into
emergency room treatment. Often private hospitals transferred their
“troublesome patients” to overloaded public hospitals, a practice that became
known as “patient dumping.”[41]
Rationing based on ability to pay remained of prime importance in the US
healthcare system even after desegregation.
Accompanying
this rise of hospitals was the rise of private health insurance. While the postwar
era is often looked back on with nostalgia, Hoffman points out that the private
healthcare coverage system left many uninsured. Employment based health
insurance coverage depended on a person’s occupation. Thus, low wageworkers,
farmers, small business employees, Blacks, and seniors were often left
uncovered.[42]
In addition, those who were covered by insurance found that many health plans
were limited and paid only partial costs of treatment. Private health insurance
plans had exclusions, “conditions not covered by policy.”[43]
A major type of exclusion was the preexisting condition clause. Under the
preexisting condition clause, patients with diseases prior to getting insurance
would not be covered since they were considered a financial liability. When
insurances companies did accept patients with “preexisting” diseases, the
patients faced high premiums. Additional insurance company limitations were deductibles
and copayments. Deductible are a set amount of money patients have to pay
before their insurance plans kicked in. Copayments are a fixed amount of money
that a patient must pay when receiving a health service. Thus, until a patient
had paid off their deductible amount they were in effect, uninsured. These
measures were called “cost-sharing” methods served as a reminder that health
insurance coverage was not free care.[44]
The problem was that as price of medical care continued to rise, the deductible
amounts and copayments also continued to rise. Rising costs of health services
forced patients to overuse hospital services instead of their primary care
physician. All was good while the economy was booming, but rapidly increasing
costs would come to haunt Americans later during economic downturns.
In
part 3: New Entitlements and New Movements, Hoffman lays down the pillars of
her main argument of health care rationing. Health care rights are central to breaking
the US rationing of healthcare. Federal programs aimed to help previously
excluded groups of the impoverished and seniors gain health insurance coverage.
Medicare and Medicaid were successfully passed through the combined efforts of
both President John F. Kennedy and President Lyndon B. Johnson. President
Kennedy started the battle by using public support to advocate for Medicare.
President Johnson outmaneuvered the opposition through political negotiations. However,
while the programs did increase health insurance coverage they did not fix the
public-private issue of the US healthcare system. Rather there were glaring
issues with both Medicare and Medicaid. The number one fatal flaw of Medicare was
that it lacked “mechanisms for cost control.”[45]
The result was that doctors and hospitals began to charge more for their
services. Hoffman states that the decade following Medicare’s passage “the
average cost per patient per day more than doubled, and hospitals’ total assets
rose from $16.4 billion to $47.3 billion.”[46]
Medicaid suffered from means testing and the accompanying stigma of social
welfare. Medicaid means tests checked
out patient backgrounds to determine whether or not patients were eligible for
the program. The large difference between Medicare and Medicaid exemplified how
the “long held notion that the poor and the middle class and affluent deserve
different types of care became the law of the land.”[47]
In
following chapter, The Rise of Health Care Activism, Hoffman applauds the push
by social movements to acknowledge health care as a right. Blacks fought
against medical inequality following desegregation. The battle was over the
poor quality of medical facilities treating Black neighborhoods. In response to
deteriorating health services, community activists protested hospital flight
and even began their own community health clinics. Other activists used
Hill-Burton’s uncompensated care clause as a legal weapon against hospitals.[48]
The National Welfare Rights Organization (NWRO) fought for the medical rights
of “welfare mothers.”[49]
Latinos fought for health care equality as well through local community
efforts. Feminists Women movements opened independent health clinics and argued
for maternity insurance and affordable childcare. Despite the gallant effort by
the activists, Hoffman states, “these changes did not fundamentally transform
the health care system or the distribution of power and resources within it.”[50]
Despite
the push for increasing health care coverage, the end of the Johnson
administration brought forth an end to the healthcare rights. Hoffman’s subheading
“From Rights to Cost Control” tells how the new Presidency of Richard Nixon
changed the rhetoric of health care from one of rights to cost control.[51]
The key to implement these new health changes were the ideas of employer based
health insurance and health maintenance organizations (HMO). Here Hoffman
displays Nixon’s health proposal as an anathema to the idea of national
healthcare. She explains how Nixon’s proposal was similar in tone to the AMA by
including copayments and means testing.[52]
Although President Nixon was unable to push forward his health care proposal,
he set the stage for future presidents to view the issue of health care as one
of cost control instead of rights.[53]
Placing the issue of health care on controlling costs, led to a focus on
trimming coverage or cutting care.
Part
4: Rights vs. Markets, demonstrates the growing problem of rising health care
costs and the continually poor US health care coverage. Ronald Reagan’s
administration focused on cutting health care expenses. Congress slashed
Medicaid budgets and some states restricted Medicaid payments to hospitals
only. The severe cuts resulted in hospitals being reimbursed for Medicaid
patients at lower price. As private hospitals transferred patients “to protect
their bottom line,” the nation faced a massive increase in patient dumping.[54]
Medicare under the Reagan presidency fared no better. In 1983, Reagan created
the Diagnostic Related Groups (DRGs) to low Medicare costs. The DRGs charged
hospitals a flat fee instead of a fee-for-service. Another invention, fee
schedules was designed to lower doctors’ fees for Medicare. Hoffman asserts
that these practices were futile because hospitals and doctors started to charge
more to privately insured patients, a practice known as “cost shifting.”[55]
The
system strained by a patchwork of health care reforms reached the breaking
point in the 1980s. Americans began to see the problems of health care coverage
intruding into the middle class life. Problems once only seen on the margins of
society began to affect the classes that previously thought they were to be
covered. Hoffman’s description of the situation is bleak with falling coverage
and increase cost-sharing measures.[56]
President Clinton stepped up to tackle the healthcare issue with his plan for HMOs
and “managed competition.”[57]
Hoffman labels Clinton’s health reform proposal as “dauntingly complex and
difficult to understand.”[58]
The proposal also suffered from the fact that it lacked strong supporters on
the wide spectrum of public support to physicians groups. Thus by 1994
Clinton’s proposal was dead.
Hoffman’s
epilogue wraps up her study of health care rationing with an analysis of
President Barack Obama’s Patient Protection and Affordable Care Act (PPACA).[59]
Hoffmann notes that despite the PPACA ban on private insurance exploitation of
the preexisting condition clause and increased efforts towards preventative
services, the PPACA does not declare healthcare to be a right. Instead the
PPACA is a mix of patient protection and cost cutting. High deductibles and
caps leave many patients with the problem of paying for their healthcare
services. Under this new system Americans have the right to a subsidy to buy
insurance. Thus, the new system works within the private market beliefs of
purchasing coverage. However, the subsidies apply only to a narrow group of
people not already covered by employer insurance. The result is a complex mix
of different insurance plans. Despite such set backs Hoffman has a sympathetic
stance towards the PPACA evident in her statement, “it is not surprising that
the 2010 health reform sends so many mixed messages about rights and
rationing.”[60]
She imagines a possible benefit of the PPACA in getting every citizen to think
about health insurance before closing out with a quote by Surgeon General, C.
Everett Koop.
Health Care for Some is a detailed
history of the development of US health industry and of uninsured Americans. Her
coverage from the Great Depression to the PPACA highlights the long pattern of
continuing issues of “rationed” healthcare. From the paying fee-for-service to the
exclusions practiced by private health insurances, groups of Americans
constantly suffered from lack of insurance or lack of coverage. During the
Great Depression, the original model of patients directly paying for fees came
under attack, as many Americans could no longer afford to pay for health
services. During the postwar, hospitals began to dominate the health scene with
their massive influx of federal funding from Hill-Burton. Despite the rapid
rise in hospital facilities, Americans face denials of care because hospitals
aimed to maintain their privileged stance on their legal right to refuse
patients. To account for the problem of hospital fees, hospitals and private
health insurance companies developed insurance plans for hospital coverage.
These private insurance companies would go on to dominate the market for health
insurance for both hospitals and doctors. However, the private stance of health
insurance has resulted in its treatment as a private commodity for profit.
Insurance companies thus excluded patients at risk for illness or denied
payments for “unnecessary services.”[61]
Government intervention via Medicaid and Medicare services only fixed surface
issues without aiming at the core of the matter. The problems of limited
insurance coverage still resonant to this day with issues about cost-sharing
methods of deductibles and copayment.
Hoffman’s
leftist leanings are on full display again with her criticism of the US health
system. The regular opponents against national health insurance: physicians
under the AMA, hospitals, and private insurance companies are viewed as
antagonists throughout the book. They continuously defy government efforts to
regulate the medical sector because they want to remain in control of their
monetary policy, in spite of receiving federal subsidies. In the realm of
politics Hoffman is always excoriating Republicans for cutting federal spending
for health services and giving more power to private companies. On the other
hand, Democrats are displayed as admirable in extending health coverage, but
mistaken in the ultimate long-term results of their actions. The mistake of
preferring governmental programs to help patch-up gaps in health care coverage
has led to wild eye spending in Medicare and Medicaid. The rising costs of
these programs have in turn pressured the premium rates on other health
insurance plans. Hoffman’s, in between the lines, suggestion is that health
care should be treated as a right of every American citizen. Categorizing
Americans into different groups depending on ability to pay and other factors
results in a mismatch of different programs, open to exploitation by politicians
and private entities.
The
problem with Hoffman’s view on healthcare rights is that she contradicts her
own writing. In her earlier book, Wages
of Sickness, Hoffman laments over the defeat of the NY compulsory health
insurance bill as a significant defeat for national healthcare. However, the
proposal set forth by the AALL excluded high-income workers, the unemployed, nonworking
poor, migrant and or seasonal workers, and Blacks.[62]
Based on the scathing criticism against health care rationing and exclusion in Health Care for Some, it is doubtful
whether or not the NY compulsory health insurance bill would have made a
difference due to limitations of the bill. The bill would likely remain within
the state for workers only, serving as an example for rationing by occupation
and by location. Her optimism for PPACA under the Obama administration is
equally troubling. Hoffman clearly states, “PPACA does not declare health care
to be a right.”[63]
The issue of rights so central to her earlier arguments against healthcare
rationing is mollified in the discussion about the PPACA. Instead of “mixed
messages,” the PPACA clearly does not go far enough in mandating universal
health coverage as a right.[64]
Deductibles still plague patients and the conglomerate of different plans:
employer based, Medicaid, and Medicare still exists. The private insurers are taxpayer-subsidized
just like hospitals under the Hill-Burton act. Expecting these private entities
to minimize their overhead and provide more services is ludicrous. PPACA is a
far cry from national health care and activists must fight to have health acknowledged
as a right.
Health Care for Some is an excellent
monograph for a discussion about the history of health care coverage. Each era
is analyzed in detail to describe how the US health care system continues to
deprive certain groups of Americans coverage. Hoffman aim is to link this
denial of coverage to rationing. By providing evidence of healthcare
“rationing” throughout US history, she can counter the fear mongering claims of
opponents against national healthcare.[65]
Although a bit conflicting towards the end, Hoffman’s overall argument that
healthcare rationing has contributed to high costs is well founded.
Bibliography
Hoffman, Beatrix. Health
Care for Some: Rights and Rationing in the United States since 1930.
Hoffman, Beatrix. The
Wages of Sickness: The Politics of Health Insurance in Progressive America.
Chapel Hill: University of North Carolina Press, 2001.
[1] Beatrix Hoffman, The Wages of Sickness: The Politics of Health
Insurance in Progressive America (Chapel Hill: University of North Carolina
Press, 2001), 2.
[4] Hoffman, Wages of Sickness, 29-32, 34.
[5] The AALL excluded the very
people they were trying to help from compulsory health care discussions. Refer
Hoffman, Wages of Sickness, 28.
[6] Hoffman notes how the AALL
was political naïve as well. Refer Hoffman, Wages
of Sickness, 44.
[7] Gompers had good reason for
expecting that health insurance would pacify the workers for Bismarck pursued
national health insurance in Germany for that very reason. Refer Hoffman, Wages of Sickness, 47-48.
[9] NCF claimed that the
British National Insurance Act damaged the quality if medical care. NICB
research centered on the benefits of employer based benefits to steal the
momentum away from compulsory health insurance. Refer Hoffman, Wages of Sickness, 51, 94-95, 105.
[10] Hoffman, Wages of Sickness, 94.
[11] In order to avoid confusion
between the author and Fredrick Ludwig Hoffman, I will refer to him as Fredrick
Hoffman.
[12] Fredrick Hoffman even gets
his own subheading, The Case of Fredrick Hoffman, in the book. Refer Hoffman, Wages of Sickness, 60-62.
[13] Hoffman, Wages of Sickness, 108-110.
[14] Hoffman, Wages of Sickness, 134.
[15] Hoffman, Wages of Sickness, 113.
[16] Hoffman, Wages of Sickness, 141.
[17] Hoffman, Wages of Sickness, 145.
[18] Hoffman, Wages of Sickness, 66.
[19] Hoffman, Wages of Sickness, 65.
[20] John B. Andrews of the AALL
gives up the fight. Refer to Hoffman, Wages
of Sickness, 177.
[21] “However, I am satisfied
that the demand for [health insurance] on the part of those most concerned will
finally override the ignorance and the willful misrepresentation of such a
system by the opposition.” Refer to Hoffman, Wages of Sickness, 187.
[22] Hoffman, Wages of Sickness, 181.
[23] This statement precedes her
“formative moment” statement. Refer Hoffman, Wages of Sickness, 2.
[24] Beatrix Hoffman, Health Care for Some: Rights and Rationing in
the United States since 1930 (Chicago: University of Chicago Press, 2012),
xv.
[25] Hoffman, Health Care for Some, xiii.
[26] Hoffman, Health Care for Some, xxv.
[27] “Charity patients accounted
for 40–50% of all patients admitted to voluntary hospitals nationwide in 1933.”
Refer Hoffman, Health Care for Some,
8.
[28] Hoffman, Health Care for Some, 10.
[29] Proportion of Blacks to
white patients varied from 35%-0%. Refer Hoffman, Health Care for Some, 12.
[30] Figure 1 demonstrates the
long lines at the waiting room of a clinic. Refer Hoffman, Health Care for Some, 13.
[32] Two of FDR’s closest
friends and advisors were doctors. Refer Hoffman, Health Care for Some, 25.
[33] Hoffman, Health Care for Some, 30.
[35] The AMA cautiously
supported hospital insurance because it did not infringe on the private
practice physicians payments. Refer Hoffman, Wages of Sickness, 35.
[36] Hoffman, Health Care for Some, 68-69.
[38] The specification of
Hill-Burton was known as the “uncompensated care clause.” Refer Hoffman, Health Care for Some, 71.
[39] Fitting into the “separate
but equal” policy. Refer Hoffman, Health
Care for Some, 74.
[40] Figure 3 demonstrates the
separate colored ward. Refer Hoffman, Health
Care for Some, 73.
[41] Hoffman, Health Care for Some, 80.
[42] Hoffman, Health Care for Some, 91.
[44] Hoffman, Health Care for Some, 106.
[45] Hoffman, Health Care for Some, 127.
[46] Hoffman, Health Care for Some, 128-129.
[48] One example of a legal
victory was Cook v. Ochsner Foundation Hospital, which legally forced hospitals
to accept Medicaid patients. Refer to Hoffman, Health Care for Some, 146.
[49] Hoffman, Health Care for Some, 147-149.
[50] Hoffman notes that movement
succeeded in eroding physician authority, promoting individual empowerment, and
beginning the breakdown of racial and gender barriers in medical schools. Refer
Hoffman, Health Care for Some, 159.
[51] Hoffman, Health Care for Some, 163.
[52] Nixon and AMA proposals are
grouped together in the same paragraph. Refer Hoffman, Health Care for Some, 164.
[53] The Watergate scandal
overshadowed Nixon’s health care proposal. However, all presidents since then
have focused on cost control instead of health care rights. Refer Hoffman, Health Care for Some, 164-166.
[54] Hoffman, Health Care for Some, 172.
[55] Hoffman, Health Care for Some, 176.
[56] Hoffman, Health Care for Some, 182-183.
[57] Clinton’s reforms rejected
centralized single payer system in favor of plan where private insurers
competed for the business of purchasers. Refer Hoffman, Health Care for Some, 183.
[59] Also known by the vernacular
term ObamaCare.
[61] Hoffman, Health
Care for Some, 191.
[62] Hoffman, Wages of Sickness, 29-31.
[64] Hoffman, Health
Care for Some, 219.
[65] The standard image of
rationing brings to mind “shortages, waiting lists, and long lines.” Refer
Hoffman, Health Care for Some, ix.
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