Friday, December 26, 2014

A little health reform history (and a quiz!)

Identify the source of the following statement: "The problem of providing satisfactory medical service to all the people of the United States at costs which they can meet is a pressing one. . . . many persons do not receive service, . . . [and the costs] are inequitably distributed. The result is a tremendous amount of preventable physical pain and mental anguish, needless deaths, economic inefficiency, and social waste."

A little health reform history (and a quiz!)

President Johnson delivering his "War on Poverty" speech in1964. Did HE say it? (Associated Press)
President Johnson delivering his "War on Poverty" speech in1964. Did HE say it? (Associated Press)

Identify the source of the following statement:

The problem of providing satisfactory medical service to all the people of the United States at costs which they can meet is a pressing one. At the present time, many persons do not receive service, which is adequate either in quantity or quality, and the costs of service are inequitably distributed. The result is a tremendous amount of preventable physical pain and mental anguish, needless deaths, economic inefficiency, and social waste.

Was it:

A) President Barack Obama's speech to a joint session of Congress in 2010, his first official State of the Union address?
B) President Lyndon B. Johnson's “War on Poverty” address, actually his State of the Union 50 years ago last Wednesday?

C) A report to the American people from public health, medical, and social science
experts in 1932?

D) The 2012 platform of the Green Party of the United States?

Yes! You are right. The answer is (C). It comes from a pioneering report, Medical Care for the American People issued by the Committee on the Costs of Medical Care during the Great Depression.

Reading the medical costs committee's report today makes it tempting to say, “different century, same problems.” Actually, it's not that simple. Medicine has changed, medical education has changed, the organization of health care delivery has changed, and, thanks to improvements in medicine and public health, we are far living longer—no longer succumbing to the infections and communicable diseases that killed Americans in the 1930s. Today we are living and dying from chronic conditions, heart disease, cancer, viral illnesses and accidents. We have Medicare, Medicaid and the Children's Health Insurance Program (CHIP). Nevertheless, 48 million Americans were uninsured in 2012 and, although that number will decline with full implementation of the Affordable Care Act (ACA), 26 to 27 million people are still projected to be without coverage. 

The reports of the Committee on the Costs of Medical Care offer several lessons. First, they remind us of just how long we’ve been struggling with the problems of providing Americans with effective and affordable health care. Second, they suggest how much more work lies ahead of us, regardless of the ACA. Finally, they reveal how contested issues of social provision, taxation, and our nation’s collective well-being have become in recent decades.

The Committee on the Costs of Medical Care began its work in 1926, following a conference in Washington to discuss problems arising from . . . the costs of medical care. Over the next several years it issued 26 reports on topics ranging from capital investment in hospitals to the costs of medicines, to organized medical services at Fort Benning, Ga. Many of the studies involved detailed investigations of small communities or local medical services, and they studied the health care provided by midwives, chiropractors, optometrists, and nurses, as well as what one report called “healing cults.” Many were described briefly in report No. 27, A Summary of Investigations on The Economic Aspects of the Prevention and Care of Illness.

The committee’s members were hardly a bunch of radicals looking to implement socialized medicine. The chairman, Ray Lyman Wilbur, M.D., had been president of the American Medical Association, president of Stanford University, and served as secretary of the Interior under President Herbert Hoover, a Republican, during the time the committee did its work; he later became became an outspoken critic of President Franklin D. Roosevelt's New Deal. Other members of the committee included physicians in private practice, public health leaders, social scientists, those representing what the committee termed “institutions and special Interests,” and representatives of “the public” (defined at the time as a banker, an engineer, a labor leader, and Wilbur himself, among others).

The group came about after attendees at the 1926 American Medical Association meeting, frustrated with the economic problems of the profession, decided to meet and tackle the problems. They reached out to Wilbur; others interested in looking for a comprehensive solution joined the group.

Given the period when committee-sponsored research took place, its members knew well how economic hardship limited access to needed health services and threatened the livelihoods of many professionals providing medical care. Despite this, in its final report (No. 28, Medical Care for the American People), the committee recommended  extending basic public health services, providing health insurance—including subsidies for those with low incomes—changes in the organization of medical practice, more coordination of health services, and improved training for health professionals.

The series of reports addressed the need for what was then called indigent care. They also acknowledged, in somewhat guarded terms, what we today call “health disparities,” even though the committee's own investigations neglected to survey African Americans. And while the word “taxation” has become anathema to many today, it was discussed openly in 1932. The solution to resource disparities among communities was to be met through taxes, primarily from local and state funds but, the report concluded, “in certain areas Federal aid may also be necessary.”

A minority report challenged many of the conclusions in the final report and stimulated the American Medical Association's opposition to the findings. Only two of the recommendations resulted in action. During the Depression the federal government did send money to the states for public health programs, and a Blue Cross insurance system was developed for voluntary prepayment of hospitalization costs. The other proposals in the majority report were ignored.

Some of the suggestions from 82 years ago sound similar to the Affordable Care Act, which aims to provide millions of Americans with affordable health insurance (without discrimination by gender or pre-existing conditions), increases public health and prevention programs, and attempts to improve quality and efficiency through experiments in the delivery of and reimbursement for medical services. And yes, like the Committee on the Costs of Medical Care's program for change, the ACA is ultimately a conservative one, eschewing the liberal prescription for a single-payer system be designed to cover all Americans.

This year, like last year, you’ll probably hear pundits calling Obamacare a radical scheme. Your historian friends will remind you that we’ve only gone part of the way in implementing the conservative plan first presented in 1932.

Janet Golden, a Rutgers University history professor, specializes in the histories of medicine, childhood and women.


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What is public health — and why does it matter?

Through prevention, education, and intervention, public health practitioners - epidemiologists, health policy experts, municipal workers, environmental health scientists - work to keep us healthy.

It’s not always easy. Michael Yudell, Jonathan Purtle, and other contributors tell you why.

Michael Yudell, PhD, MPH Associate Professor, Drexel University School of Public Health
Jonathan Purtle, DrPH, MSc Assistant Professor, Drexel University School of Public Health
Janet Golden, PhD Professor of history, Rutgers University-Camden
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