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.
Social work class brief history of us health policy
A Brief History of US Health Policy or Why Health Reform is Like Surfing
• 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
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.
18th/19th centuries =LimitedKnowledge = Not much cure
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
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.”
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.
Flexner Report: Beginning of Modern Medicine, 1910If the sick are to reap the full benefit of recentprogress in medicine, a more uniformly arduousand expensive medical education isdemanded.—Abraham Flexner1
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
What’s Public Health?“The science and art of preventing disease, prolonginglife, and promoting physical health . . Through . . .Sanitation of the environment, control of infections,education of the individual in personal hygiene, theorganization of medical and nursing services, . . . Andthe development of the social machinery which willensure to every individual in the community a standardof living adequate for the maintenance of health.”Charles Winslow, Professor of Public Health, Yale, 1920
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.
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.
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
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
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
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
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
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
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
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
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.
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.
The Father of Medicare Rhode Island Democrat Founder and first president Council of Senior Citizens
Medicare 1965 • Lyndon B Johnson • Democrat from Texas • President 1963- 1969 • The Great Society • War on Poverty
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)
Part D: Drug Coverage• $350 Deductible• 25% co-payments• Coverage Gap $2,930 - $4,700• “Doughnut Hole”
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”
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
Who Is Not Covered• Does not cover all poor people• Very Few parents• No single adults• Guys like thisNot covered
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
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
Medicare Modernization Act 2003 • President 2000-2008 • Republican • Medicare Part D • Doughnut Hole