Chat with us, powered by LiveChat Revolutionary Influences 200 words total Prior to beginning work on this discussion, review your textbook chapters for this w - School Writers

Revolutionary Influences 200 words total Prior to beginning work on this discussion, review your textbook chapters for this w

 Week 1 Discussion 2: Revolutionary Influences 200 words total

Prior to beginning work on this discussion, review your textbook chapters for this week and read the article The History of Healthcare Quality: The First 100 Years 1860–1960 and review Healthcare Timeline (Links to an external site.) and A Brief History: Universal Health Care Efforts in the US (Links to an external site.) and A Brief History: Universal Health Care Efforts in the US (Links to an external site.).

Chapter 2 in your textbook discusses the evolution of our health care system. Much of it evolved due to the political landscape, societal constraints, consumer demand, escalating costs, and technological advancement. Legislation and legal cases also influenced the health care system considerably. After reading Chapter 2 in your textbook, review the time line simulation Global Perspectives: Shifts in Science and Medicine That Changed Healthcare (Links to an external site.) in the Summary and Resources page.

Consider how the U.S. health care system has evolved over the past 50 years. In your post,

  • Choose one of the influencing factors from the Global Perspectives: Shifts in Science and Medicine That Changed Healthcare time line and discuss its impact on the health care system.
  • Rationalize why your chosen influencing factor has been revolutionary for the health care system.

A Brief History: Universal Health Care Efforts in the US (Transcribed from a talk given by Karen S. Palmer MPH, MS in San

Francisco at the Spring, 1999 PNHP meeting)

Late 1800’s to Medicare

The campaign for some form of universal government-funded health care

has stretched for nearly a century in the US On several occasions,

advocates believed they were on the verge of success; yet each time they

faced defeat. The evolution of these efforts and the reasons for their failure

make for an intriguing lesson in American history, ideology, and character.

Other developed countries have had some form of social insurance (that

later evolved into national insurance) for nearly as long as the US has been

trying to get it. Some European countries started with compulsory sickness

insurance, one of the first systems, for workers beginning in Germany in

1883; other countries including Austria, Hungary, Norway, Britain, Russia,

and the Netherlands followed all the way through 1912. Other European

countries, including Sweden in 1891, Denmark in 1892, France in 1910, and

Switzerland in 1912, subsidized the mutual benefit societies that workers

formed among themselves. So for a very long time, other countries have

had some form of universal health care or at least the beginnings of it. The

primary reason for the emergence of these programs in Europe was

income stabilization and protection against the wage loss of sickness

rather than payment for medical expenses, which came later. Programs

were not universal to start with and were originally conceived as a means

of maintaining incomes and buying political allegiance of the workers.

In a seeming paradox, the British and German systems were developed by

the more conservative governments in power, specifically as a defense to

counter expansion of the socialist and labor parties. They used insurance

against the cost of sickness as a way of “turning benevolence to power”.

US circa 1883-1912, including Reformers and the Progressive Era:

What was the US doing during this period of the late 1800’s to 1912? The

government took no actions to subsidize voluntary funds or make sick

insurance compulsory; essentially the federal government left matters to

the states and states left them to private and voluntary programs. The US

did have some voluntary funds that provided for their members in the case

of sickness or death, but there were no legislative or public programs

during the late 19th or early 20th century.

In the Progressive Era, which occurred in the early 20th century, reformers

were working to improve social conditions for the working class. However

unlike European countries, there was not powerful working class support

for broad social insurance in the US The labor and socialist parties’ support

for health insurance or sickness funds and benefits programs was much

more fragmented than in Europe. Therefore the first proposals for health

insurance in the US did not come into political debate under anti-socialist

sponsorship as they had in Europe.

Theodore Roosevelt 1901 — 1909

During the Progressive Era, President Theodore Roosevelt was in power

and although he supported health insurance because he believed that no

country could be strong whose people were sick and poor, most of the

initiative for reform took place outside of government. Roosevelt’s

successors were mostly conservative leaders, who postponed for about

twenty years the kind of presidential leadership that might have involved

the national government more extensively in the management of social

welfare.

AALL Bill 1915

In 1906, the American Association of Labor Legislation (AALL) finally led

the campaign for health insurance. They were a typical progressive group

whose mandate was not to abolish capitalism but rather to reform it. In

1912, they created a committee on social welfare which held its first

national conference in 1913. Despite its broad mandate, the committee

decided to concentrate on health insurance, drafting a model bill in 1915. In

a nutshell, the bill limited coverage to the working class and all others that

earned less than $1200 a year, including dependents. The services of

physicians, nurses, and hospitals were included, as was sick pay, maternity

benefits, and a death benefit of fifty dollars to pay for funeral expenses.

This death benefit becomes significant later on. Costs were to be shared

between workers, employers, and the state.

AMA supported AALL Proposal

In 1914, reformers sought to involve physicians in formulating this bill and

the American Medical Association (AMA) actually supported the AALL

proposal. They found prominent physicians who were not only

sympathetic, but who also wanted to support and actively help in securing

legislation. In fact, some physicians who were leaders in the AMA wrote to

the AALL secretary: “Your plans are so entirely in line with our own that we

want to be of every possible assistance.” By 1916, the AMA board approved

a committee to work with AALL, and at this point the AMA and AALL

formed a united front on behalf of health insurance. Times have definitely

changed along the way.

In 1917, the AMA House of Delegates favored compulsory health insurance

as proposed by the AALL, but many state medical societies opposed it.

There was disagreement on the method of paying physicians and it was

not long before the AMA leadership denied it had ever favored the

measure.

AFL opposed AALL Proposal

Meanwhile the president of the American Federation of Labor repeatedly

denounced compulsory health insurance as an unnecessary paternalistic

reform that would create a system of state supervision over people’s

health. They apparently worried that a government-based insurance

system would weaken unions by usurping their role in providing social

benefits. Their central concern was maintaining union strength, which was

understandable in a period before collective bargaining was legally

sanctioned.

Private insurance industry opposed AALL Proposal

The commercial insurance industry also opposed the reformers’ efforts in

the early 20th century. There was great fear among the working class of

what they called a “pauper’s burial,” so the backbone of insurance business

was policies for working class families that paid death benefits and

covered funeral expenses. But because the reformer health insurance

plans also covered funeral expenses, there was a big conflict. Reformers

felt that by covering death benefits, they could finance much of the health

insurance costs from the money wasted by commercial insurance policies

who had to have an army of insurance agents to market and collect on

these policies. But since this would have pulled the rug out from under the

multi-million dollar commercial life insurance industry, they opposed the

national health insurance proposal.

WWI and anti-German fever

In 1917, the US entered WWI and anti-German fever rose. The government-

commissioned articles denouncing “German socialist insurance” and

opponents of health insurance assailed it as a “Prussian menace”

inconsistent with American values. Other efforts during this time in

California, namely the California Social Insurance Commission,

recommended health insurance, proposed enabling legislation i

n 1917, and then held a referendum. New York, Ohio, Pennsylvania, and

Illinois also had some efforts aimed at health insurance. But in the Red

Scare, immediately after the war, when the government attempted to root

out the last vestiges of radicalism, opponents of compulsory health

insurance associated it with Bolshevism and buried it in an avalanche of

anti-Communist rhetoric. This marked the end of the compulsory national

health debate until the 1930’s.

Why did the Progressives fail?

Opposition from doctors, labor, insurance companies, and business

contributed to the failure of Progressives to achieve compulsory national

health insurance. In addition, the inclusion of the funeral benefit was a

tactical error since it threatened the gigantic structure of the commercial

life insurance industry. Political naivete on the part of the reformers in

failing to deal with the interest group opposition, ideology, historical

experience, and the overall political context all played a key role in shaping

how these groups identified and expressed their interests.

The 1920’s

There was some activity in the 1920’s that changed the nature of the

debate when it awoke again in the 1930’s. In the 1930’s, the focus shifted

from stabilizing income to financing and expanding access to medical care.

By now, medical costs for workers were regarded as a more serious

problem than wage loss from sickness. For a number of reasons, health

care costs also began to rise during the 1920’s, mostly because the middle

class began to use hospital services and hospital costs started to increase.

Medical, and especially hospital, care was now a bigger item in family

budgets than wage losses.

The CCMC

Next came the Committee on the Cost of Medical Care (CCMC). Concerns

over the cost and distribution of medical care led to the formation of this

self-created, privately funded group. The committee was funded by 8

philanthropic organizations including the Rockefeller, Millbank, and

Rosenwald foundations. They first met in 1926 and ceased meeting in 1932.

The CCMC was comprised of fifty economists, physicians, public health

specialists, and major interest groups. Their research determined that there

was a need for more medical care for everyone, and they published these

findings in 26 research volumes and 15 smaller reports over a 5-year

period. The CCMC recommended that more national resources go to

medical care and saw voluntary, not compulsory, health insurance as a

means to covering these costs. Most CCMC members opposed

compulsory health insurance, but there was no consensus on this point

within the committee. The AMA treated their report as a radical document

advocating socialized medicine, and the acerbic and conservative editor of

JAMA called it “an incitement to revolution.”

FDR’s first attempt — failure to include in the Social Security Bill of 1935

Next came Franklin D. Roosevelt (FDR), whose tenure (1933-1945) can be

characterized by WWI, the Great Depression, and the New Deal, including

the Social Security Bill. We might have thought the Great Depression

would create the perfect conditions for passing compulsory health

insurance in the US, but with millions out of work, unemployment

insurance took priority followed by old age benefits. FDR’s Committee on

Economic Security, the CES, feared that inclusion of health insurance in its

bill, which was opposed by the AMA, would threaten the passage of the

entire Social Security legislation. It was therefore excluded.

FDR’s second attempt — Wagner Bill, National Health Act of 1939

But there was one more push for national health insurance during FDR’s

administration: The Wagner National Health Act of 1939. Though it never

received FDR’s full support, the proposal grew out of his Tactical

Committee on Medical Care, established in 1937. The essential elements of

the technical committee’s reports were incorporated into Senator

Wagner’s bill, the National Health Act of 1939, which gave general support

for a national health program to be funded by federal grants to states and

administered by states and localities. However, the 1938 election brought a

conservative resurgence and any further innovations in social policy were

extremely difficult. Most of the social policy legislation precedes 1938. Just

as the AALL campaign ran into the declining forces of progressivism and

then WWI, the movement for national health insurance in the 1930’s ran

into the declining fortunes of the New Deal and then WWII.

Henry Sigerist

About this time, Henry Sigerist was in the US He was a very influential

medical historian at Johns Hopkins University who played a major role in

medical politics during the 1930’s and 1940’s. He passionately believed in a

national health program and compulsory health insurance. Several of

Sigerist’s most devoted students went on to become key figures in the

fields of public health, community and preventative medicine, and health

care organization. Many of them, including Milton Romer and Milton Terris,

were instrumental in forming the medical care section of the American

Public Health Association, which then served as a national meeting ground

for those committed to health care reform.

Wagner-Murray-Dingell Bills: 1943 and onward through the decade

The Wagner Bill evolved and shifted from a proposal for federal grants-in-

aid to a proposal for national health insurance. First introduced in 1943, it

became the very famous Wagner-Murray- Dingell Bill. The bill called for

compulsory national health insurance and a payroll tax. In 1944, the

Committee for the Nation’s Health, (which grew out of the earlier Social

Security Charter Committee), was a group of representatives of organized

labor, progressive farmers, and liberal physicians who were the foremost

lobbying group for the Wagner-Murray-Dingell Bill. Prominent members of

the committee included Senators Murray and Dingell, the head of the

Physician’s Forum, and Henry Sigerist. Opposition to this bill was enormous

and the antagonists launched a scathing red baiting attack on the

committee saying that one of its key policy analysts, I.S. Falk, was a conduit

between the International Labor Organization (ILO) in Switzerland and the

United States government. The ILO was red-baited as “an awesome

political machine bent on world domination.” They even went so far was to

suggest that the United States Social Security board functioned as an ILO

subsidiary. Although the Wagner-Murray-Dingell Bill generated extensive

national debates, with the intensified opposition, the bill never passed by

Congress despite its reintroduction every session for 14 years! Had it

passed, the Act would have established compulsory national health

insurance funded by payroll taxes.

Truman’s Support

After FDR died, Truman became president (1945-1953), and his tenure is

characterized by the Cold War and Communism. The health care issue

finally moved into the center arena of national politics and received the

unreserved support of an American president. Though he served during

some of the most virulent anti-Communist attacks and the early years of

the Cold War, Truman fully supported national health insurance. But the

opposition had acquired new strength. Compulsory health insurance

became entangled in the Cold War and its opponents were able to make

“socialized medicine” a symbolic is

sue in the growing crusade against Communist influence in America.

Truman’s plan for national health insurance in 1945 was different than FDR’s

plan in 1938 because Truman was strongly committed to a single universal

comprehensive health insurance plan. Whereas FDR’s 1938 program had a

separate proposal for medical care of the needy, it was Truman who

proposed a single egalitarian system that included all classes of society,

not just the working class. He emphasized that this was not “socialized

medicine.” He also dropped the funeral benefit that contributed to the

defeat of national insurance in the Progressive Era. Congress had mixed

reactions to Truman’s proposal. The chairman of the House Committee

was an anti-union conservative and refused to hold hearings. Senior

Republican Senator Taft declared, “I consider it socialism. It is to my mind

the most socialistic measure this Congress has ever had before it.” Taft

suggested that compulsory health insurance, like the Full Unemployment

Act, came right out of the Soviet constitution and walked out of the

hearings. The AMA, the American Hospital Association, the American Bar

Association, and most of then nation’s press had no mixed feelings; they

hated the plan. The AMA claimed it would make doctors slaves, even

though Truman emphasized that doctors would be able to choose their

method of payment.

In 1946, the Republicans took control of Congress and had no interest in

enacting national health insurance. They charged that it was part of a large

socialist scheme. Truman responded by focusing even more attention on a

national health bill in the 1948 election. After Truman’s surprise victory in

1948, the AMA thought Armageddon had come. They assessed their

members an extra $25 each to resist national health insurance, and in 1945

they spent $1.5 million on lobbying efforts which at the time was the most

expensive lobbying effort in American history. They had one pamphlet that

said, “Would socialized medicine lead to socialization of other phases of

life? Lenin thought so. He declared socialized medicine is the keystone to

the arch of the socialist state.” The AMA and its supporters were again very

successful in linking socialism with national health insurance, and as anti-

Communist sentiment rose in the late 1940’s and the Korean War began,

national health insurance became vanishingly improbable. Truman’s plan

died in a congressional committee. Compromises were proposed but none

were successful. Instead of a single health insurance system for the entire

population, America would have a system of private insurance for those

who could afford it and public welfare services for the poor. Discouraged

by yet another defeat, the advocates of health insurance now turned

toward a more modest proposal they hoped the country would adopt:

hospital insurance for the aged and the beginnings of Medicare.

After WWII, other private insurance systems expanded and provided

enough protection for groups that held influence in American to prevent

any great agitation for national health insurance in the 1950’s and early

1960’s. Union-negotiated health care benefits also served to cushion

workers from the impact of health care costs and undermined the

movement for a government program.

Why did these efforts for universal national health insurance fail again?

For may of the same reasons they failed before: interest group influence

(code words for class), ideological differences, anti-communism, anti-

socialism, fragmentation of public policy, the entrepreneurial character of

American medicine, a tradition of American voluntarism, removing the

middle class from the coalition of advocates for change through the

alternative of Blue Cross private insurance plans, and the association of

public programs with charity, dependence, personal failure and the

almshouses of years gone by.

For the next several years, not much happened in terms of national health

insurance initiatives. The nation focussed more on unions as a vehicle for

health insurance, the Hill-Burton Act of 1946 related to hospital expansion,

medical research and vaccines, the creation of national institutes of health,

and advances in psychiatry.

Johnson and Medicare/caid

Finally, Rhode Island congressman Aime Forand introduced a new

proposal in 1958 to cover hospital costs for the aged on social security.

Predictably, the AMA undertook a massive campaign to portray a

government insurance plan as a threat to the patient-doctor relationship.

But by concentrating on the aged, the terms of the debate began to

change for the first time. There was major grass roots support from seniors

and the pressures assumed the proportions of a crusade. In the entire

history of the national health insurance campaign, this was the first time

that a ground swell of grass roots support forced an issue onto the national

agenda. The AMA countered by introducing an “eldercare plan,” which was

voluntary insurance with broader benefits and physician services. In

response, the government expanded its proposed legislation to cover

physician services, and what came of it were Medicare and Medicaid. The

necessary political compromises and private concessions to the doctors

(reimbursements of their customary, reasonable, and prevailing fees), to

the hospitals (cost plus reimbursement), and to the Republicans created a

3-part plan, including the Democratic proposal for comprehensive health

insurance (“Part A”), the revised Republican program of government

subsidized voluntary physician insurance (“Part B”), and Medicaid. Finally, in

1965, Johnson signed it into law as part of his Great Society Legislation,

capping 20 years of congressional debate.

What does history teach us? What is the movement reacting to?

1. Henry Sigerist reflected in his own diary in 1943 that he “wanted to use

history to solve the problems of modern medicine.” I think this is,

perhaps, a most important lesson. Damning her own naivete, Hillary

Clinton acknowledged in 1994 that “I did not appreciate how

sophisticated the opposition would be in conveying messages that

were effectively political even though substantively wrong.” Maybe

Hillary should have had this history lesson first.

2. The institutional representatives of society do not always represent

those that they claim to represent, just as the AMA does not represent

all doctors. This lack of representation presents an opportunity for

attracting more people to the cause. The AMA has always played an

oppositional role and it would be prudent to build an alternative to the

AMA for the 60% of physicians who are not members.

3. Just because President Bill Clinton failed doesn’t mean it’s over. There

have been periods of acquiescence in this debate before. Those who

oppose it can not kill this movement. Openings will occur again. We all

need to be on the lookout for those openings and also need to create

openings where we see opportunities. For example, the focus on

health care costs of the 1980’s presented a division in the ruling class

and the debate moved into the center again. As hockey great Wayne

Gretzky said, “Success is not a matter of skating to where the puck is, it

is a matter of skating to where the puck will be.”

4. Whether we like it or not, we are going to have to deal with the

persistence of the narrow vision of middle class politics. Vincente

Navarro says that the majority opinion of national health insurance has

everything to do with repression and coercion by the capitalist

corporate dominant class. He argues that the conflict and struggles

that continuously take place around the issue of health care unfold

within the parameters of class and that coercion and

repression are forces that determine policy. I think when we talk about

interest groups in this country, it is really a code for class.

5. Red-baiting is a red herring and has been used throughout history to

evoke fear and may continue to be used in these post Cold War times

by those who wish to inflame this debate.

6. Grass roots initiatives contributed in part to the passage of Medicare,

and they can work again. Ted Marmor says that “pressure groups that

can prevail in quiet politics are far weaker in contexts of mass attention

— as the AMA regretfully learned during the Medicare battle.” Marmor

offers these lessons from the past: “Compulsory health insurance,

whatever the details, is an ideological controversial matter that

involves enormous financial and professional stakes. Such legislation

does not emerge quietly or with broad partisan support. Legislative

success requires active presidential leadership, the commitment of an

Administration’s political capital, and the exercise of all manner of

persuasion and arm-twisting.”

7. One Canadian lesson — the movement toward universal health care in

Canada started in 1916 (depending on when you start counting), and

took until 1962 for passage of both hospital and doctor care in a single

province. It took another decade for the rest of the country to catch on.

That is about 50 years all together. It wasn’t like we sat down over

afternoon tea and crumpets and said please pass the health care bill

so we can sign it and get on with the day. We fought, we threatened,

the doctors went on strike, refused patients, people held rallies and

signed petitions for and against it, burned effigies of government

leaders, hissed, jeered, and booed at the doctors or the Premier

depending on whose side they were on. In a nutshell, we weren’t the

sterotypical nice polite Canadians. Although there was plenty of

resistance, now you could more easily take away Christmas than

health care, despite the rhetoric that you may hear to the contrary.

8. Finally there is always hope for flexibility and change. In researching

this talk, I went through a number of historical documents and one of

my favorite quotes that speaks to hope and change come from a 1939

issue of Times Magazine with Henry Sigerist on the cover. The article

said about Sigerist: “Students enjoy his lively classes, for Sigerist does

not mind expounding his dynamic conception of medical history in

hand-to-hand argument. A student once took issue with him and

when Dr. Sigerist asked him to quote his authority, the student

shouted, “You yourself said so!” “When?” asked Dr. Sigerist. “Three

years ago,” answered the student. “Ah,” said Dr. Sigerist, “three years is

a long time. I’ve changed my mind since then.” I guess for me this

speaks to the changing tides of opinion and that everything is in flux

and open to renegotiation.

Acknowledgements:

Special thanks to medical historians and PNHP colleagues Corinne Sutter-

Brown and Ted Brown for background information, critical analysis, and

editing.

References:

Much of this talk was paraphrased/annotated directly from the sources

below, in particular the work of Paul Starr:

1. Bauman, Harold, “Verging on National Health Insurance since 1910” in

Changing to National Health Care: Ethical and Policy Issues (Vol. 4,

Ethics in a Changing World) edited by Heufner, Robert P. and Margaret

# P. Battin, University of Utah Press, 1992.

2. “Boost President’s Plan”, Washington Post, p. A23, February 7, 1992.

Brown, Ted. “Isaac Max Rubinow”, (a biographical sketch), American

Journal of Public Health, Vol. 87, No. 11, pp. 1863-1864, 1997

3. Danielson, David A., and Arthur Mazer. “The Massachusetts

Referendum for a National Health Program”, Journal of Public Health

Policy, Summer 1986.

4. Derickson, Alan. “The House of Falk: The Paranoid Style in American

House Politics”, American Journal of Public Health”, Vol. 87, No. 11, pp.

1836 – 1843, 1997.

5. Falk, I.S. “Proposals for National Health Insurance in the USA: Origins

and Evolution and Some Perspectives for the Future’, Milbank

Memorial Fund Quarterly, Health and Society, pp. 161-191, Spring 1977.

6. Gordon, Colin. “Why No National Health Insurance in the US? The

Limits of Social Provision in War and Peace, 1941-1948”, Journal of

Policy History, Vol. 9, No. 3, pp. 277-310, 1997.

7. “History in a Tea Wagon”, Time Magazine, No. 5, pp. 51-53, January 30,

1939.

8. Marmor, Ted. “The History of Health Care Reform”, Roll Call, pp. 21,40,

July 19, 1993.

9. Navarro, Vicente. “Medical History as a Justification Rather than

Explanation: Critique of Starr’s The Social Transformation of American

Medicine” International Journal of Health Services, Vol. 14, No. 4, pp.

511-528, 1984.

10. Navarro, Vicente. “Why Some Countries Have National Health

Insurance, Others Have National Health Service, and the United States

has Neither”, International Journal of Health Services, Vol. 19, No. 3, pp.

383-404, 1989.

11. Rothman, David J. “A Century of Failure: Health Care Reform in

America”, Journal of Health Politics, Policy and Law”, Vol. 18, No. 2,

Summer 1993.

12. Rubinow, Isaac Max. “Labor Insurance”, American Journal of Public

Health, Vol. 87, No. 11, pp. 1862 – 1863, 1997 (Originally published in

Journal of Political Economy, Vol. 12, pp. 362-281, 1904).

13. Starr, Paul. The Social Transformation of American Medicine: The rise

of a sovereign profession and the making of a vast industry. Basic

Books, 1982.

14. Starr, Paul. “Transformation in Defeat: The Changing Objectives of

National Health Insurance, 1915-1980”, American Journal of Public

Health, Vol. 72,

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