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 healthcare discussions. I also agree that Hoffman’s analysis is important
to understanding the 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 the
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 for these services.
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 book covers a large span of time resulting in 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 bothered me 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. 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.
The Wages of Sickness begins with an explanation of the health care
situation prior to the proposal for compulsory health insurance. She describes
the New York health care system as a mixture of various health support services.
This mixture of healthcare 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 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. The
public perception of compulsory health insurance as a foreign concept 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 he
believed that the plan would undermine trade union benefits and stop the battle
for higher wages.[8]
Medical professionals (The 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 the 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. 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 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 an excellent read. 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’s 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 for the 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 of compulsory health care
insurance. Gompers is depicted as a traitor to labor through his dealings with
Fredrick Hoffman.[16]
Fredrick Hoffman is portrayed as a behind the scene schemer that outright lies
to the AALL.[17]
Mark Daly and Thaddeus Sweet are illustrated as self-serving businessmen. Hoffman’s
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.[18]
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. 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. The AFL’s betrayal is demonstrated with
Gomper’s secret dealing with Fredrick Hoffman. Manufacturers are clearly
colluding as shown through their affiliated 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 failure of 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. 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.”[19]
However, the decline of unionized labor is not accounted for. 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 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.[20]
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 the burden of cost on patients.
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 healthcare system demonstrated the inadequacy
of standard health services. Public county hospitals, already strained to the
limit, were hit badly by financial difficulties from patient unable to pay for
health services.[21]
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 served
patients with specific conditions such as tuberculosis or sexual transmitted
diseases.[22]
Another form of explicit rationing was race. Clinics refused or had quotas for
African American patients.[23]
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 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.[24]
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.[25]
As an alternative he pressed for hospital legislation.[26]
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.”[27]
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. Nevertheless, Blue Cross and Blue Shield were both limited to
hospital service and did not cover primary physician office visits. Still the
development of health insurance meant that private solutions became the new
standard to dealing with medical payment plans.[28]
After
the end of the World War II, America witnessed a massive hospital construction
program. Hoffman links the rise of hospitals to the Hill-Burton Act of 1946.
The act gave federal funds to hospitals without any additional supervision
because increasing the number of hospitals was suppose to provide more health
care to Americans.[29]
Despite increasing the number of hospitals, groups of patients were continually
being denied access to hospital treatment.
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 this specification.[30]
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 of segregated of
facilities.[31]
Black and White patients were kept separate from each other and given different
hospital wings.[32]
These denials of care 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.”[33]
Accompanying
this rise of hospitals was the rise of private health insurance. Even with increasing
coverage among Americans, 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.”[34]
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.[35]
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 citizens 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.”[36]
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.”[37]
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, middle class, and affluent deserve different types of
care became the law of the land.”[38]
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.”[39]
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.[40]
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.”[41]
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.[42]
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.[43]
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.”[44]
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 covered. Hoffman’s description of the
situation is bleak with falling coverage and increasing cost-sharing measures.[45]
President Clinton stepped up to tackle the healthcare issue with his plan for
HMOs and “managed competition.”[46]
Yet his proposal was “dauntingly complex and difficult to understand.”[47]
The proposal also suffered from a lack of strong supporters on a 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).[48]
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 to pay 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 a right to 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.”[49]
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.”[50]
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.”[51]
Her admiration is evident when she recommends the book to anyone desiring to be
an informed citizen. 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.[52]
His first critique is that book loses sight of some important details such as
organ procurement and Title VI prohibition. His second critique is that the
book “leaves a impression that not much has changed.”[53]
His response clearly indicates that Smith is more knowledgeable about the topic
of healthcare than the other two reviewers.[54]
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, despite
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 Americans coverage. Sprinkled throughout
the book are the personal horror stories of health care denial we periodically
hear in the news. Hoffman aims 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.[55]
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 workers, and Blacks.[56]
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 the limitations of the bill. The bill most likely would have remained
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.”[57]
The issue of rights so central to her earlier arguments against healthcare
rationing is mollified in her discussion about the PPACA. Instead of “mixed
messages,” the PPACA clearly does not go far enough in mandating universal
health coverage as a right.[58]
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 services acknowledged as a right.
Both
of Hoffman’s books, The Wages of Sickness
and Health Care for Some tie into
our class discussion about healthcare in the United States. In the Wages of Sickness, the AMA and employers
are two of the factions against compulsory healthcare. From our class readings
on the AMA and occupational health the opposition of these two groups comes as
no surprise.[59]
The role of the AMA was to consolidate the authority of medicine over one sect,
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.”[60]
Further support came from progressives 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.”[61]
In effect, he called for a reduction in the number of incompetent medical
professionals, the removal of sectarianism in favor of modern medicine, and a
formation of tightly defined standards of schooling. These ideals were in line
with progressive thoughts 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.”[62]
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 the 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.[63]
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 such as 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. This shortage brought forth complaints by some critics that
the new medical standards set by the states had lowered 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.[64]
However, the report asserts that decreasing the standards of medicine would not
increase the number of physicians in rural areas. Rather the 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 greater attractions
than the isolated village.”[65]
The article ironically rules out specialists as a possible source of rural
disparity and calls the creation of a sub-standard physician class as
“impracticable.”[66]
At the time of the Rockefeller Foundation, specialists were a small minority of
the medical establishment; by 1990s specialists outnumbered physicians. The
decreasing number of primary care physicians has also led to the present day 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 week of “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.”[67]
However, his call for national health insurance faced the same opposition that
the AALL faced. The AMA’s resistance to 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.”[68]
Devoto chides such thinking as “so unrealistic that it suggests the need of
psychiatric scrutiny,” and believes that the AMA needs “some realistic
instruction in the facts of modern life.”[69]
From our present day viewpoint we can see 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 that there were factions within the AMA that
differ from the official party 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.”[70]
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.”[71]
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 at
the annual AMA meeting.[72]
Like in The Wages of Sickness, opposition
to national health insurance united these groups together.
The
power of private health insurance and private hospitals, 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 insurance
coverage needed for the rising prices of medical treatments. 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.”[73]
First, healthcare is not a like other commodities, its funding and use are
particularly open to exploitation that will result in price inflation and over
utilization.[74]
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.”[75]
Third, the medical profession must act decisively to “separate physicians from
commercial exploitation of healthcare” and physicians should have “no economic
conflict of interest.”[76]
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,” the elimination of low use,
unprofitable services and exclusion of unprofitable patients.[77]
Fifth, private emphasis on procedures and technology runs the risk of excluding
personal care resulting in the “fragmentation of care, overspecialism, and
overemphasis on expensive technology.”[78]
The sixth and final danger is that a 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
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.[79]
Physicians have come under attack especially during the 1970s and 1980s as
exploitive players part of the healthcare system.[80]
The exclusion of “unprofitable” patients led to widespread “patient dumping” in
the 1980s.[81]
Specialists have overtake primary care physicians and services for medical care
are now in demand more than ever especially with new diagnostic tools such as
the CT and MRI scan.
Beatrix
Hoffman’s two works help to simplify the history of healthcare from 1930 to the
present. The history of health coverage has revealed an implicitly and
explicitly rationed healthcare system. Originally a completely fee-for-service
system, healthcare costs had risen so much that insurance was required to be
able to adequately pay medical bills. Private insurance was developed to meet
these financial needs, but only served as a temporary relief. Too many were
excluded from coverage and those “covered” turned out not to be with the abundance
of “cost sharing” measures. Federal attempts to address this health crisis have
run the gauntlet of political debates and face stiff opposition from the
private sector. The argument of “Americanism” seen during the battle for NY
compulsory health insurance has remained a strong feature of the healthcare
debate. The patriotic, nationalistic sentiment of exceptionalism defines
national health care as a foreign concept unsuited to the rugged,
individualistic, free market nature of America. However, nationalist ideology is
not immune from the problems of health and sickness. In this case, healthcare
is granted to those deemed “worthy” a nod, once again, to the ideology of
“Americanism.” Unfortunately, even with the “patchwork” US healthcare coverage,
the economics of medicine do not match up to Americanism. Costs continue to
climb to ever-greater heights leaving Americans to foot the bill. These alarming
expenses have changed the issue of healthcare from one of coverage to one of
costs. An overview of the American healthcare system teaches us that the
question of healthcare must be pursued as one of rights, not entitlements. For
rights are permanent while entitlements can stripped away. By working within
this ideology of rights, the government can obtain the role of authority and
regulate healthcare. Only then will Americans be able to enjoy “life, liberty,
and the pursuit of happiness.”
Bibliography
Abel, Emily K. 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 [J-Stor].
Allo, Clifford D. 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 [J-Stor].
Burnham, John C. “American Medicine's Golden Age: What Happened to it?” Science,
New Series, Vol. 215, No. 4539 (Mar.
19, 1982), pp. 1474-1479 [J-Stor].
Clemens, Elisabeth S. 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
[J-Stor].
Coombs, Jan Gregoire. 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 [Academic Search Complete, EBSCOhost].
Hoffman, Beatrix. Health Care for Some: Rights and Rationing in
the United States since 1930. Chicago:
University of Chicago Press, 2012.
Hoffman, Beatrix. The Wages of Sickness: The Politics of Health
Insurance in Progressive America.
Chapel Hill: University of North Carolina Press, 2001.
Linker, Beth. Review of Health Care
for Some: Rights and Rationing in the United States since 1930, by Beatrix Hoffman American
Historical Review 119, no. 1 (February 2014): 214-215 [Academic Search Complete, EBSCOhost].
Smith, David Barton. 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 [Project Muse].
Warner, John Harley, and Tighe, Janet Ann. Major Problems in the
History of American Medicine and
Public Health : Documents and Essays. Major Problems in American History Series. Boston: Houghton
Mifflin, 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.
[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.
[18] “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.
[19] Hoffman, The Wages of Sickness, 181.
[20] Hoffman, Health Care for Some, xxv.
[21] “Charity patients accounted
for 40–50% of all patients admitted to voluntary hospitals nationwide in 1933.”
Refer Hoffman, Health Care for Some,
8.
[22] Hoffman, Health Care for Some, 10.
[23] Proportion of Blacks to
white patients varied from 35%-0%. Refer Hoffman, Health Care for Some, 12.
[24] Figure 1 demonstrates the
long lines at the waiting room of a clinic. Refer Hoffman, Health Care for Some, 13.
[25] Two of FDR’s closest
friends and advisors were doctors. Refer Hoffman, Health Care for Some, 25.
[26] Hoffman, Health Care for Some, 30.
[28] The AMA cautiously
supported hospital insurance because it did not infringe on the private
practice physicians payments. Refer Hoffman, Health Care for Some, 35.
[29] Hoffman, Health Care for Some, 66, 68-69.
[30] The specification of
Hill-Burton was known as the “uncompensated care clause.” Refer Hoffman, Health Care for Some, 71.
[31] Fitting into the “separate
but equal” policy. Refer Hoffman, Health
Care for Some, 74.
[32] Figure 3 demonstrates the
separate colored ward. Refer Hoffman, Health
Care for Some, 73.
[33] Hoffman, Health Care for Some, 80.
[35] Hoffman, Health Care for Some, 106.
[36] Hoffman, Health Care for Some, 127.
[37] Hoffman, Health Care for Some, 128-129.
[39] Hoffman, Health Care for Some, 147-149.
[40] 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.
[41] 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.
[42] Hoffman, Health Care for Some, 163.
[43] Hoffman, Health Care for Some, 172.
[44] Hoffman, Health Care for Some, 176.
[45] Hoffman, Health Care for Some, 182-183.
[46] 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.
[48] Also known by the
vernacular term ObamaCare.
[50] 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.
[51] 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.
[52]
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.
[55] The standard image of
rationing brings to mind “shortages, waiting lists, and long lines.” Refer
Hoffman, Health Care for Some, ix.
[56] Hoffman, The Wages of Sickness, 29-31.
[58] Hoffman, Health
Care for Some, 219.
[60] 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.
[62] Ibid., 300.
[64] Warner and Tighe, Major Problems in the History of American
Medicine and Public Health, 292-293.
[67] Warner and Tighe, Major Problems in the History of American
Medicine and Public Health, 435-437.
[72] Warner and Tighe, Major Problems in the History of American
Medicine and Public Health, 435-437.
[75] Ibid., 465.
[77] Ibid.
[79] Hoffman, Health Care for Some, 127.
[80] 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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