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Social work class brief history of us health policy
1. A Brief History of US Health Policy
or Why Health Reform is Like
Surfing
2. • Why Americans, who were wary of medical authority in the 19th century, became devoted to
it in the 20th.
• How American doctors , who were divided and financially insecure in the 19th century
became a united and prosperous profession in the 20th.
• Why hospitals became the central institution of medical care and public health did not
3. continued
• Why there’s no national health insurance in the USA
• Why Blue Cross and commercial insurance dominated
the market rather than other types of health plans
• Why the federal government tries to control cost by
reorganizing medical care system
• Why physicians stayed a cottage industry in the age of
the corporation.
8. Emphasis on Prevention:
William Buchan – Domestic Medicine
An attempt to render the medical
art more generally useful, by
showing people what is in their
own power both with respect
to the Prevention and Cure of
Disease.
• First published in 1769
• 30 editions in America
• “most influential book of its
kind” Starr
12. Struggle to Create a Profession
• Physicians; surgeons and barbers;
apothecaries
• Apprenticeship is principal form of training
• First medical school – Philadelphia 1765
• Efforts to set MDs apart from others
• Efforts at Licensure/State Laws through 1820s
• Lay medicine continues to rival “learned
professions.”
13. Strategies to Create a Profession
• Struggle throughout 19th century
• Science of Medicine Advances
– Bacteriological Revolution
– Anesthetic
– Aseptic
• More medical schools but quality sketchy
• States abandon licensure
• Flexner Report is the beginning of change to
profession with power, authority and improved
earnings.
14. Flexner Report: Beginning of Modern
Medicine, 1910
If the sick are to reap the full benefit of recent
progress in medicine, a more uniformly arduous
and expensive medical education is
demanded.—Abraham Flexner1
15. What’s Happening in 20th Century
• Industrialization
• Labor Unions, Socialism, Progressive Movement
• Demands to protect workers
– Loss of income – workers comp
– Payment for medical care
• Germany establishes first compulsory sickness
insurance for workers 1883, Sweden, Denmark,
France
• Growth of public health and the Dispensary
16. What’s Public Health?
“The science and art of preventing disease, prolonging
life, and promoting physical health . . Through . . .
Sanitation of the environment, control of infections,
education of the individual in personal hygiene, the
organization of medical and nursing services, . . . And
the development of the social machinery which will
ensure to every individual in the community a standard
of living adequate for the maintenance of health.”
Charles Winslow, Professor of Public Health, Yale, 1920
17.
18. Public Health Loses to Private
Medicine
• Turn of century is “golden age” of public health;
enormous progress
• Public Health Dispensaries compete with private
doctors – push-back
• Public health relegated to secondary status; less
prestigious, less well financed and blocked from
assuming higher level functions of coordination
by being banned from medical care.
19. Why the US did not develop universal
health insurance system
• No national political health champion emerges
• Health coverage promoted by leaders outside
government – American Association for Labor Legislation
• Tied to Socialism (rather than as strategy against
it)
• Threat to medical profession – Blocked by AMA
• WWI - “A dangerous plot by the Kaiser” the
Wiener becomes a hot dog.
20. The Presidents and Health Insurance
• Teddy Roosevelt
• Supported Health Insurance
• “no country can be strong
whose people are sick and
poor”
• Defeated in 1912 by Wilson
• WWI 1914-18
21. The New Deal and Health Insurance
FDR 1932 - 1945
• Priorities: Unemployment
Insurance; Old Age Benefits
• Health Insurance would have
to wait
• “We can’t go up against the
medical Societies, we just
can’t do it.” FDR 1943
• WWII: We will pass a bill
after the War FDR 1944
22. The Buck Stops Here: Harry Truman
1945-52
• Context: Cold War, Foreign policy
preoccupation
• Wants to Extend New Deal
• Nov 1945 called upon Congress
To pass a national program to assure
The right to adequate medical care and
Protection from the “economic fears,” of
sickness
• Asked for single payer system
• Medical services absorb 4% of national
• Economy; “ We can afford to spend more
• For health
23. Why 50 years of failure to achieve
universal coverage?
• Opponents cast reform in ideological terms
– Socialism; communism; cold war
• Public opinion malleable
– Wanted insurance but not sure what kind
• Opponents vastly outspent supporters
– 1950 supporters spent $36,000
– 1950 AMA spent $2.25 million
• Health insurance expanded to well-off and
well-organized but no universalism
24. Private Insurance
• Defeat of universalism leads to fragmented
private system.
• Price controls lead employers to offer health
insurance as benefit
• Rising hospital costs create demand for
insurance
• Hospital controlled plans emerge
25. The Birth of the Blues
• Start: Baylor University Hospital provides 1,500
school teachers up to 21 days in hospital at $6
per person/per year (1929)
• Multi-hospital, community-wide plans develop
under hospital control
• AMA supports group plans; tries to maintain
control
• States pass enabling legislation for nonprofit
plans
• Blue Shield partners with Blue Cross
26. Unions Enter the Fray
• National Labor Relations Act (Wagner Act)
gave unions collective bargaining rights (1935)
• After WWII, unions include health benefits in
bargaining
• By 1954, 29 million workers/families enrolled
in health benefit plans
• UMWA Health Fund 1948
27. Cooperatives/Pre-paid plans
• Medical cooperatives flourish in cities/fail in
rural areas
• Group Health Cooperative of Puget Sound
most successful- worker sponsored
• Kaiser Permanente – employer sponsored
28. Private Solutions Trump Public Efforts
• In 1950/60s development of various insurance plans
(indemnity, HMO); employer coverage meet the
need and dampen demand for universal government
supported solution; works for the middle class
• Medical workforce increases from 1.2 to 3.9 million
(1950-1970)
• National health expenditures grew from $12.7 billion
to $71.6 billion (GDP 4.5 -7.3%)
• Medical care becomes one of the nations largest
industries.
29. The Elderly Are Left Out
• Medicare introduced in 1958 by RI Congressman
• Cover hospital costs for elderly
• Hospital care doubled in price in 1950s
• Senate subcommittee on aging holds hearings
• President Kennedy supports Medicare but does
not have the votes to pass it.
• Democratic sweep in 1964 puts Medicare on top
of the list of Great Society programs.
30. The Father of Medicare
Rhode Island Democrat
Founder and first
president
Council of Senior Citizens
31. Medicare 1965
• Lyndon B Johnson
• Democrat from Texas
• President 1963- 1969
• The Great Society
• War on Poverty
33. Medicare : Compromise Plan
• Part A: Compulsory Hospital Insurance under
SS (Dem Plan) ; no fees for elderly
• Part B: Government subsidized voluntary
insurance to cover physician bills (Republican
Plan) ; elderly pay depending on income
• Medicaid: Assistance to the states for medical
care for the poor
• Part D: Prescription Drug Coverage (passed
2003, effective 2006)
34. Part D: Drug Coverage
• $350 Deductible
• 25% co-payments
• Coverage Gap $2,930 - $4,700
• “Doughnut Hole”
35. Medicaid
• An after-thought
• Not a federal program like Medicare
• A federal/ state partnership
• In WV 75%/25% fed/state partnership
• From modest beginnings grown to address
multiple needs
• Read “Medicaid Made Simple”
36. Medicaid: Who’s Covered in WV?
• 400,000 + West Virginians
• Elderly – 80,000
• People with Disabilities 100,000+
• Children 200,000+
• Pregnant women 11,000+
• Parents with dependent children earning less
than 35% of FPl
37. Who Is Not Covered
• Does not cover all poor people
• Very Few parents
• No single adults
• Guys like this
Not covered
38. Mandate for Growth Ends by 1970
• Efforts at cost control
– Comprehensive health planning to reduce hospital
beds (Nixon)
– Delivery System Reforms for HMOs (Nixon)
– DRGs (Reagan) End of Cost-based reimbursement
39. Clinton Health Reform 1993
• National Reform Fails 1993
National Reform
• Republican Sweep Fails 1993
Republican Sweep
• CHIP 1997
1994
• Bipartisan effort
CHIP 1997
Bipartisan effort
Paul Star, The Social Transformation of American Medicine; the Rise of a Sovereign Profession and the making of a vast industryBest book of its kindShows how the development of medicine as a profession and political movements interacted to create the kind of system we haveToday. Nothing about our system today is inevitable. It is the result of the interaction of politics, science, economics and professional power and interest working their way through the 19th and 20th centuries. You can’t understand public policy of health care without understanding the rise of the Allopathic medical profession – Allopathic medicine was in prior centuries just one tradition among many othersBut it became the dominant tradition.In West Virginia, we have the Osteopathic medical school in Lewisburg.It came from a very different tradition of body manipulation – more like chiropracty.Today, however, it has adapted to be about the same as the allopathic tradition and has same power and respect.
I included this for the Yuk factorAlthough Leeches are making a come-back in modern medicineNext slide
The bark from willow trees has been used as analgesic for centuries; chemical properties of this plant produced aspirin
Wonder Drugs from the Garden: Chamomile, Rosemary, Ginseng
PlagueApoplecticThere was a lot of identification of disease CancerGangreneVomitingKilled by falling down stairsSore legg etc.
In this world, the physician is trying to make money and achieve recognition as a professional Physicianshad more status; never worked with their handsSurgeons and barbers were in same professional classEfforts to elevate the profession and separate it from lay healers
Public health had big aspirations at the beginning of the 20th century.
Lot of agitation for universal health system; European nations are doing itWorkers are demanding it. But it did not happen.
Unions give up on universalism and make their own deals
Group health Puget Sound organized by Aero Mechanics union, local supply and food coops.
So, by now, you should be able to answer the question. Why is health reform like surfing.If you, as a politician contemplate it, know you are getting into dangerous waters.Prepare: Get your wet suit on; get your board, find some buddies to take with you.Get in the water; it seems calm; paddle and paddle some more. Paddle over a few swells which come your way.Now you’re out there. Ready to get on your board.You stand up bravely and wait for the wave to come.You could get knocked down immediately – like ClintonOr you could begin to ride the wavePrepare to be knocked over and dragged down.If you are really lucky and you are very skilled andThe wave is with you, you ride to shore and something big has been accomplished.To ride a wave like that, you have to be from Hawaii.
