Beatrix Hoffman, a
professor of history at Northern Illinois University, has provided a strong
argument in favor of national health insurance with her two books: The Wages of Sickness: The Politics of
Health Insurance in Progressive America and Health Care for Some: Rights and Rationing in the United States since
1930. Her first book, The Wages of
Sickness, is about the failed proposal for compulsory health insurance in
New York. The proposal rode on the wave of progressivism during the late 19th
and early 20th century and appeared destined to pass. However, the
proposal met a tragic end in New York legislation after coming across fierce
opposition. The book is essentially a study about how a fractured support and united
opposition resulted in the failure of New York’s first compulsory healthcare
proposal. Hoffman argues that the failure of this early proposal 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]
General historical reviews about The
Wages of Sickness agree on the important influence of the book because of
recent discussions about health insurance are in full swing. I also agree that Hoffman’s
analysis is important to understanding opposition to national health insurance.
However, my problem with The Wages of
Sickness is that 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. Thankfully this drawback in The Wages of Sickness is covered by her
other book Health Care for Some.
Health Care for Some is a history of American health coverage from
20th century into the 21st century. America has always
suffered from a lack of reliable medical professionals resulting in a mixture
of various health services and different levels of coverage. Hoffman describes this
system of health coverage that provides for some, but not others as
“rationing.” She further 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.”[2]
The large time period covered has resulted in book reviews that praise Hoffman
for her daring, but also critique her for leaving out some details. During my
reading of the book the only issue that came to mind was the contradiction in
her concluding stance on the Patient Protection and Affordable Care Act and her
earlier book, The Wages of Sickness. The
tone of her writing is critical throughout the book only to change to hopeful at
the end. Both of Beatrix Hoffman’s books cover the issue of health coverage
with clear writing accompanied by moving narratives. Based on the situations
depicted in The Wages of Sickness and
Health Care for Some, it is clear to
perceive that national health insurance can only be successfully pursued if it
is declared a right.
Hoffman’s The Wages of Sickness begins with an
explanation of the health care situation prior to the proposal of compulsory
health insurance. She describes the New York health care system as a mixture of
various health support services. This mixture of health care coverage offered a
“patchwork of protection” consisting of fraternal societies, trade unions,
employer sickness plans, commercial health and life insurance plans, and
charity medicine.[3]
Later she introduces us to the organizational sponsor of the compulsory health
insurance proposal, the American Association for Labor Legislation (AALL). The
AALL defined itself as a bureau of “experts” with the aim of worker protection.[4]
Drawing from successful European models, the AALL 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.[5]
Hoffman next highlights
the AALL’s failure to garner support and its underestimation of the opposition.
The organization’s failures were because of their “expert” and third party
stance that led them to exclude workers and employers from discussions.[6]
Because the AALL previously passed workers compensation reforms without
significant resistance, they naïvely expected that the workers and employers
would support them. Even when opposition against the proposal started to
develop in the form of Americanism, the AALL dismissed it as a “smokescreen for
the material interest of their opponents.”[7]
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 public perception of compulsory
health insurance as foreign became a reality in term of political clout. Time
and time again the opposition would prove more capable at using publicity.
The cohesive 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.[8]
Medical professionals (Major organization being the American Medical
Association also known as AMA) feared that compulsory health insurance plans
would decrease their incomes. Employers, such as Mark Daly and Thaddeus Sweet, were
in a similar line of thought and believed that premiums for the health
insurance would eat into their profits. Insurance companies, notably Prudential
Insurance Company and its vice president Frederick Hoffman, 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.
In comparison to the
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.”[9]
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.
Hoffman ends 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 rhetoric.[10]
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.[11]
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.
Book reviews of The Wages of Sickness are generally positive
describing the book as excellent read that would interest those involved with health
insurance policy. Emily K. Abel’s review of the book is one example of this
standard. Abel starts off with a catchy opening describing a possible situation
where national health care is labeled as violating basic American values. From
there she provides a simple summary noting the opposition, Gompers, and time as
factors that led to defeat of the compulsory health insurance bill. She concludes
by recommending this “excellent book” for “historians of public health,
business, labor, women, and public policy.”[12]
Clifford D. Allo’s review of the book differs from Abel in recommendation and
summary. In the introduction, he recommends the book to “anyone interested in
public policy,” a larger group than Abel’s historians.[13]
Allo summary of the book is also more in depth covering specific individuals
mentioned such as Pauline Newman and Frederick L. Hoffman. He concludes by stating
the book’s potential as a “baseline” comparison past and present.[14]
Elisabeth S. Clemens differs from the other reviewers in her concluding
remarks. While she admits that Hoffman’s argument is persuasive, Clemens notes
that resistance to government intervention during the Prohibition “suggests
deeper currents of resistance to policy expansion.”[15]
She then proposes that The Wages of
Sickness serves as a call for deeper studies about opposition to reform in
politics. Clemens does not specifically recommend the book to any group of
people.
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. Hoffman partiality towards the women’s
movement is evident in her light treatment of Florence Kelly and high acclaim
for Pauline Newman. Kelly is presented as a good-intentioned, misinformed
speaker. Pauline Newman is discussed in a rather admiring way for her sharp
retorts against the opposition. Hoffman even goes as far as to end the book
with a quote from Newman.[16]
The Wages of Sickness does a superb job at presenting the reasons
for the defeat of compulsory health insurance. Rather than solely attack the
opposition on moral grounds, Hoffman demonstrates how each group of the
opposition stands gain with clarity. Private correspondence and memos generate
a view of the opposition’s conversation. Quotes and photographs of specific
individuals involved help the reader imagine the scene. Gompers’ contradictory
stance on compulsory health insurance is demonstrated in his secret dealing
with Fredrick Hoffman. Manufacturers are clearly colluding as shown through the
associations. Sweet’s role establishes the link between legislation and
business. The division within labor is given equal coverage. NYSFL’s break from
the AFL’s stance indicates a major rift between labor unions. Newman’s battle
with Kelly and LEO depicts another split within labor. The opposition of
mainstream labor, employers, medical professionals, and private insurance
companies along with divided grassroots support ensured the defeat of
compulsory health care.
Hoffman falls short in
her attempt 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 an opposition that would continue to resist for the rest
of the century. The healthcare system was already fragmented before the
proposal for compulsory health insurance. 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.”[17]
Even if the rest opposition did continue to oppose health insurance, but the
book does not cover in detail 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. The whole issue is essentially skimmed over within the epilogue
of the book. Fortunately, Hoffman’s Health
Care for Some goes more in depth about the continued resistance to universal
health insurance.
Beatrix Hoffman’s Health Care for Some starts off similar
to The Wages of Sickness. First, she
describes how medical care in early colonial America was a local
responsibility. Hoffman then proceeds to discuss the issue of the right to
health care. Of great importance to the discussion are the two different types
of health care rationing, explicit and implicit. Explicit rationing denies care
according to an official set of rules written out. Implicit rationing is the
denial of care through the factors of life such as the ability to pay. Both
forms of rationing occur throughout the book and are symptoms of a lack of
health care rights. The US Declaration of Independence and the US Constitution
made no mention of a right to health.[18]
Hoffman next brings up the NY battle for compulsory health insurance from The 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.
The first half of Health Care for Some describes how the
impact of the Great Depression resulted in the formation of the American
medical empire with its vast hospital system and private insurance coverage. The
severity of the depression forced the issue of health insurance back into the
spotlight. A sudden massive influx of former middle class Americans to the
poorly coordinated public-private health care system demonstrated the
inadequacy of standard health services. Public county hospitals, already
strained to the limit, were also hit by financial difficulties from patient
unable to pay for health services.[19]
With large patient loads, rationing became even more pronounced. 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.[20]
Another form of explicit rationing was race. Clinics refused or had quotas for
African American patients.[21]
Implicit rationing came in the form of long distances to and from health
services as well as time limits. Time was another implicit rationing that
restricted 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.[22]
Those that were unable to see the doctor had to revisit repeatedly since many
clinics operated on a first come first serve basis.
President Franklin D.
Roosevelt (FDR) refused to commit permanent federal funds to healthcare because
he wanted to avoid antagonizing the AMA.[23]
As an alternative he pressed for hospital legislation.[24]
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 marking the beginning of health insurance. Hoffman
agrees that Blue Cross was “a success.”[25]
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 hospital
doctors’ fees. However, Blue Cross and Blue Shield were both limited to
hospital service and did not cover primary physician office visits. Private
health care solutions thus became the new standard to dealing with medical
payment plans.[26]
After
the end of the World War II, America witnessed a rise in hospitals. Hoffman
links the rise of hospitals to the Hill-Burton Act of 1946. The act gave
federal funds to hospitals without any oversight because increasing the number
of hospitals was suppose to provide more health care to Americans.[27]
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.[28]
Hospitals had the financial incentive to lower their free care since the act
also required hospitals to be self-sufficient after receiving 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.[29]
Black and White patients were kept separate from each other and given different
hospital wings.[30]
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.”[31]
Accompanying
this rise of hospitals was the rise of private health insurance. Some groups
continued to be excluded from coverage. In addition, those 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.”[32]
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.
Additional insurance company limitations were deductibles and copayments.
Deductibles are a set amount of money patients have to pay before their
insurance coverage kicks 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
“cost-sharing” methods served as a reminder that health insurance coverage was
not free care.[33]
The problem was that as price of medical care continued to rise, the deductible
amounts and copayments also continued to rise. All was good while the economy
was booming, but rapidly increasing costs would come to haunt Americans later
during economic downturns.
The
second half of Health Care for Some centers
on the battle for health care rights as the issue becomes more about cost. Medicare
and Medicaid were major health care programs that aimed to help previously
excluded groups of the impoverished and seniors gain health insurance coverage.
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.”[34]
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.”[35]
Medicaid suffered from means testing and the accompanying stigma of social
welfare. The 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.”[36]
The
1960s and 1970s witnessed a massive social movement to acknowledge health care
as a right. Blacks fought against medical inequality following desegregation. 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. The National Welfare Rights
Organization (NWRO) fought for the medical rights of “welfare mothers.”[37]
The struggle was over the poor quality of medical facilities treating underserved
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.[38]
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.”[39]
The
end of the Johnson administration brought forth a new era of focusing on healthcare
costs instead of rights. The new Presidency of Richard Nixon with its plans for
employer based health insurance and health maintenance organizations (HMOs) reflected
this change.[40]
However, he was unable to push forward his health care proposal as his
administration was caught up in the Watergate scandal. Ronald Reagan would be
the next major president to pass cuts on health care expenses. Congress slashed
Medicaid budgets, restricting Medicaid payments in some states to hospitals
only. Hospitals were being reimbursed for Medicaid patients at lower price. This
led to an epidemic of patient dumping.[41]
Medicare fared no better. In 1983, Reagan created the Diagnostic Related Groups
(DRGs) to low Medicare costs. Instead of a fee-for-service, DRGs charged hospitals
a flat fee. 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.”[42]
The
health care system reached its breaking point in the 1980s. Americans began to
see the problems of health care coverage intruding into middle class life. Insurance
problems, once only seen on the margins of society, began to affect classes
that previously thought they were to be covered. Hoffman’s description of the
situation is bleak with falling coverage and increasing cost-sharing measures.[43]
President Clinton stepped up to tackle the healthcare issue with his plan for
HMOs and “managed competition.”[44]
Yet his proposal was “dauntingly complex and difficult to understand.”[45]
The proposal also suffered from the fact that it lacked strong supporters on
the wide spectrum. 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).[46]
Hoffmann notes that the PPACA is a mix of patient protection and cost cutting. PPACA
bans the preexisting condition clause and increases efforts towards
preventative services. There are still high deductibles and caps leaving
patients the problem of paying for their healthcare services. The most glaring
issue is that the PPACA does not declare healthcare to be a right. Under this
new system Americans have the right to a subsidy to buy insurance, but not
healthcare. Therefore, the new system applies 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.”[47]
She ends believing that the PPACA serves a greater purpose in getting citizens
to debate over healthcare.
Book
reviews of Health Care for Some are favorable,
but contain some criticism or none at all. Jan Gregoire Coombs’ review is a
plain and simple summary. In the beginning he compliments the book as “a well
documented, detailed account of why the United States has failed to provide
healthcare for all Americans.”[48]
Past the introduction is a basic summary of the book without any recommendations
or criticism. Beth Linker’s review is more active in its praise. She lauds the
book as a “smart, lively, and highly readable account” of America’s healthcare
system and sees the book as a great service for the “voting public.”[49]
Her admiration is evident when she recommends the book to anyone desiring to be
an informed citizens and even users of the American healthcare system. However,
Linker offers one suggestion of socialized medicine that she believes that
Hoffman has not covered, the US Veterans Health Administration. David Barton
Smith’s review is more critical when compared to the other two. Although he
commends the book for being “well-researched and clearly written” with “rich,
painful anecdotes,” he saves his heavy criticism for the latter half of his
review.[50]
His first criticism is that book loses sight of some important details such as
organ procurement and Title VI prohibition. His second criticism is that the
book “leaves a impression that not much has changed.”[51]
His response clearly indicates that Smith is more knowledgeable about the topic
of healthcare than the other two reviewers.[52]
Hoffman’s
leftist leanings are on full display again with her criticism of the US health
system. 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 using governmental programs
to patch-up gaps in health care coverage has led to wild eye spending in
Medicare. The rising costs of these programs have in turn pressured the premium
rates on other health insurance plans. Hoffman’s 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.
Health Care for Some is an excellent
monograph for discussing the history of health care coverage. The reading is
not too information dense and Hoffman does a good job explaining aspects of
medical care. Each era is analyzed in detail to describe how the US health care
system continues to deprive certain groups of Americans coverage. Sprinkled
throughout the book are the personal horror stories of health care denial we
periodically hear in the news. 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.[53]
The
problem with Hoffman’s view on healthcare rights is that she contradicts her
own writing. In her earlier book, The
Wages of Sickness, Hoffman laments over the defeat of the NY compulsory
health insurance bill as a significant defeat for the development of 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.[54]
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.”[55]
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.[56]
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.
Both
of Hoffman’s books, The Wages of Sickness
and Health Care for Some tied
into our class discussion about the issue of healthcare in the United States.
In the Wages of Sickness, the AMA and
employers are two factions against the compulsory healthcare. From our class
readings on the AMA and occupational health the opposition of these two groups
comes as no surprise.[57]
The role of the AMA was to consolidate the authority of medicine over one sect
of allopathy. They did this by gaining support from states governments, which
created licensing boards. State licensing boards required “candidates to hold a
diploma from a reputable medical school” and “required an examination.”[58]
Further support came from progressive supporters such as Abraham Flexner. In
his famous, Flexner report, he advocated for the need for a “smaller number of
medical schools better equipped and better conducted.”[59]
In effect, he called for a reduction in the number of incompetent medical
professionals, removal of sects in favor of modern medicine, and tightly
defined standards of schooling. These ideals were in line with progressive thinking
of a need to regulate industries for the benefit of the consumer. Indeed,
regular medical professionals attempted to portray their monopolization of the
health industry as a humanitarian decision. In reality, the regular medical
profession “zealously fought to subordinate and control allied health
personnel.”[60]
The AMA’s opposition to compulsory health insurance demonstrates how the
humanitarian rhetoric was a cover for what they really wanted to protect, a
fee-for-service system and the right to refuse patients.
Employers
have a poor record of maintaining their workers’ health. Accidents on site were
often blamed on worker rather than the employer. The assumption of risk,
contributory negligence, and fellow servant rule were terms thrown around by
employers to avoid compensating injured workers.[61]
Even after these accidents were later covered by workers’ compensation,
employers brought in company doctors to limit reimbursement. An overview of
employer response to chronic occupational health issues of phossy jaw and
radium poisoning yields additional evidence demonstrating how far companies
were willing to go to ignore the health of their workers. The radium girls had
to spend years working with the law before they were reimbursed. Companies
overlooked terrible phossy jaw deaths because they were unwilling to turn to a
more expensive alternative of red phosphorous. To employers healthcare was seen
as yet another unnecessary expense cutting from their bottom line.
Shortly
after the standardization and state licensing of medicine, rural areas faced
doctor shortages, especially in rural areas. This shortage brought forth
complaints by some critics that the new medical standards set by the states had
reduced medical care for Americans by reducing the quantity of physicians. The
Rockefeller Foundation’s Report in 1924 confirmed the rural areas of the US
were facing physician shortages.[62]
However, the report asserts that decreasing the standards of medicine will not
increase the number of physicians in rural areas. Rather this lack of
physicians in the rural areas remains an chronic problem in medical care because
the environment for “the city and the town have always offered to the average
physician greater attractions than the isolated village.”[63]
The article ironically rules out specialists as possible sources of rural
disparity and calls the creation of a sub-standard physician class as
“impracticable.”[64]
At the time of the Rockefeller Foundation, specialists were a small minority of
the medical establishment mostly compromised of physicians; by 1990s
specialists outnumbered physicians. The decreasing number of primary care
physicians has led to the rise of assistant physicians (The report’s
“sub-standard physician class”).
In
Health Care for Some, the issue of
national health insurance is a pressing matter that is continually deferred
from one president to the next. Our class readings for “The Golden Age of
Medicine/Intersex” hint at the tumult surrounding national health insurance. After
the death of FDR, the mantle of national health care was passed on to President
Truman. He addressed the US Congress on May 19,1947 speaking about the need to
“bring good health care within the reach of all” Americans through “national
health insurance.”[65]
However, his call for national health insurance faced the same opposition that
the AALL faced. The AMA’s resistance Truman’s proposal is well documented. That
same year only a month later the AMA held an annual meeting at the Atlantic
City denouncing national health insurance. Journalist Bernard Devoto sums up
the AMA’s demands in one sentence, “Organized medicine insists on complete,
unsupervised control of any health program that may evolve; and it requires
that plan to interfere with the fee-for-service system as little as possible,
not at all wherever there is any to maintain the system.”[66]
Devoto chides such thinking as “so unrealistic that is suggest the need of
psychiatric scrutiny,” and believes that the AMA needs “some realistic
instruction in the facts of modern life.”[67]
From our present day viewpoint we can see the Devoto was both wrong and right.
Wrong in believing that the AMA would yield to the pressure of national health
care anytime soon. Right in believing there are factions within the AMA that
differ from the official organizational line. In fact the AMA did start to
change its policies around the 1990s, but only after physicians were “no longer
the most powerful players in the health care industry.”[68]
Hoffman
is careful to avoid placing all the blame on the AMA. In The Wages of Sickness, she notes how historians have all too often
blamed the AMA for the repeated failure of health reform attempts. She then
states, “Physicians alone did not deliver the definitive blow to the health
insurance crusade.”[69]
Indeed her entire book describes how the opposition is composed of an
assortment of interest groups. Some of these interest groups are visible in
Devoto’s article. The Philip Morris Company handed out free cigarettes. Hospitals
and research foundations had booths in the Technical Exposition. The
past-president of the National Association of Manufacturers gave a speech.[70]
Opposition to national health insurance united these groups together.
The
opposition group present in Health Care
for Some takes off to unprecedented heights with the rapid privatization of
medicine. The 20th class readings, “Health and the State” reflect on
the issues of healthcare coverage needed for the rising prices of medical
treatment. Arnold Relman in his “The New Medical-Industrial Complex” highlights
the dangers of “a vast array of investor-owned businesses supplying health
services for profit.”[71]
First, healthcare is not a like other commodities, its funding and use are
particularly open to exploitation that will result in price inflation along
with over utilization.[72]
Second, private businesses while good at controlling unit costs and quality
improvement do not fundamentally restrict their services. Rather as private
entities they seek to sell their services as much as possible, certainly not in
the interest of moderating use of medical resources. Therefore if private
industry is to be involved it will “have to be regulated.”[73]
Third, the medical profession must act decisively to “separate physicians from
commercial exploitation of healthcare” and physicians should have “no economic
conflict of interest.”[74]
If the medical establishment does not act it runs the risk of undermining its
authority when speaking on behalf of public interest. Fourth, commercialization
of healthcare runs the risk of “cream-skimming,” elimination of low use,
unprofitable services and exclusion of unprofitable patients.[75]
Fifth, private emphasis on procedures and technology runs the risk of excluding
personal care resulting in “fragmentation of care, overspecialism, and
overemphasis on expensive technology.”[76]
The sixth and final danger is that large private healthcare industry could
become a formidable political force in the country, hindering efforts to reform
healthcare policy. The present day situation of healthcare outlined in Health Care for Some has revealed that Relman’s
fears have come to pass. Private companies, hospitals, insurance and the like, have
come to play a huge role in healthcare and as a result hold considerable sway
over the healthcare policy. Unfortunately the growth of the private sector was
not followed by an equal amount of federal regulation. Federal plans like
Medicare have led to a dramatic rise in healthcare cost, as there were no
mechanisms of cost control in the original law.[77]
Physicians have come under attack especially during the 1970s and 1980s as
exploitive players part of the healthcare system.[78]
The exclusion of “unprofitable” patients led to widespread “patient dumping” in
the 1980s.[79]
Specialists have overtake primary care physicians and specialize services for
medical care are in demand more than ever especially with new diagnostic tools
such as the CT and MRI scan.
[1] Beatrix Hoffman, The Wages of Sickness: The Politics of Health
Insurance in Progressive America (Chapel Hill: University of North Carolina
Press, 2001), 2.
[2] Beatrix Hoffman, Health Care for Some: Rights and Rationing in
the United States since 1930 (Chicago: University of Chicago Press, 2012), xiii.
[5] Hoffman, The Wages of Sickness, 29-32, 34.
[6] The AALL excluded the very
people they were trying to help from compulsory health care discussions. Refer
Hoffman, The Wages of Sickness, 28.
[8] 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, The Wages of Sickness, 47-48.
[9] Hoffman, The Wages of Sickness, 145.
[10] Hoffman, The Wages of Sickness, 65.
[11] John B. Andrews of the AALL
gives up the fight. Refer to Hoffman, The
Wages of Sickness, 177.
[12] Emily K. Abel, review of The Wages of Sickness: The Politics of
Health Insurance in Progressive America, by Beatrix Hoffman, The Journal of American History 88, no.
4 (March 2002): 1556-1557.
[13] Clifford D. Allo, review of
The Wages of Sickness: The Politics of
Health Insurance in Progressive America, by Beatrix Hoffman, The American Journal of Legal History 45,
no. 2 (April 2001): 220-221.
[14] Ibid.
[15] Elisabeth S. Clemens,
review of The Wages of Sickness: The
Politics of Health Insurance in Progressive America, by Beatrix Hoffman, The Journal of Interdisciplinary History
33, no. 1 (Summer 2002): 146-147.
[16] “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, The Wages of Sickness, 187.
[17] Hoffman, The Wages of Sickness, 181.
[18] Hoffman, Health Care for Some, xxv.
[19] “Charity patients accounted
for 40–50% of all patients admitted to voluntary hospitals nationwide in 1933.”
Refer Hoffman, Health Care for Some,
8.
[20] Hoffman, Health Care for Some, 10.
[21] Proportion of Blacks to
white patients varied from 35%-0%. Refer Hoffman, Health Care for Some, 12.
[22] Figure 1 demonstrates the
long lines at the waiting room of a clinic. Refer Hoffman, Health Care for Some, 13.
[23] Two of FDR’s closest
friends and advisors were doctors. Refer Hoffman, Health Care for Some, 25.
[24] Hoffman, Health Care for Some, 30.
[26] The AMA cautiously
supported hospital insurance because it did not infringe on the private
practice physicians payments. Refer Hoffman, Health Care for Some, 35.
[27] Hoffman, Health Care for Some, 66, 68-69.
[28] The specification of
Hill-Burton was known as the “uncompensated care clause.” Refer Hoffman, Health Care for Some, 71.
[29] Fitting into the “separate
but equal” policy. Refer Hoffman, Health
Care for Some, 74.
[30] Figure 3 demonstrates the
separate colored ward. Refer Hoffman, Health
Care for Some, 73.
[31] Hoffman, Health Care for Some, 80.
[33] Hoffman, Health Care for Some, 106.
[34] Hoffman, Health Care for Some, 127.
[35] Hoffman, Health Care for Some, 128-129.
[37] Hoffman, Health Care for Some, 147-149.
[38] 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.
[39] 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.
[40] Hoffman, Health Care for Some, 163.
[41] Hoffman, Health Care for Some, 172.
[42] Hoffman, Health Care for Some, 176.
[43] Hoffman, Health Care for Some, 182-183.
[44] 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.
[46] Also known by the
vernacular term ObamaCare.
[48] Jan Gregoire Coombs, review
of The Wages of Sickness: The Politics of
Health Insurance in Progressive America, by Beatrix Hoffman, The Journal of American History 100, no.
1 (June 2013): 290-291.
[49] Beth Linker, review of The Wages of Sickness: The Politics of
Health Insurance in Progressive America, by Beatrix Hoffman, American Historical Review 119, no. 1 (February
2014): 214-215.
[50]
David Barton Smith,
review of The Wages of Sickness: The
Politics of Health Insurance in Progressive America, by Beatrix Hoffman, Journal of the History of Medicine and
Allied Sciences 69, no. 1 (January 2014): 177-179.
[53] The standard image of
rationing brings to mind “shortages, waiting lists, and long lines.” Refer
Hoffman, Health Care for Some, ix.
[54] Hoffman, The Wages of Sickness, 29-31.
[56] Hoffman, Health
Care for Some, 219.
[58] John Harley Warner and Janet Ann Tighe, Major Problems in the History
of American Medicine and Public Health: Documents and Essays, Major Problems
in American History Series (Boston: Houghton Mifflin, 2001), 299.
[60] Ibid., 300.
[62] Warner and Tighe, Major Problems in the History of American
Medicine and Public Health, 292-293.
[65] Warner and Tighe, Major Problems in the History of American
Medicine and Public Health, 435-437.
[70] Warner and Tighe, Major Problems in the History of American
Medicine and Public Health, 435-437.
[73] Ibid., 465.
[75] Ibid.
[77] Hoffman, Health Care for Some, 127.
[78] John C. Burnham, “American Medicine's Golden Age: What Happened to it?” Science,
New Series, Vol. 215, No. 4539 (Mar. 19, 1982), pp. 1474-1479 [J-Stor]
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