RRw2

132 Chapter 3 The Evol ution of H ealth Services i n the U n ited States

blow to the national health insurance movement, as anti-German feelings were aroused among the U.S. populace. The U.S. government denounced German social insurance, and opponents of health insur­ ance called it a Prussian menace, inconsis­ tent with American values (Starr, 1982).

After attempts to pass compulsory health insurance laws failed at the state levels in California and New York, AALL itself lost interest in an obviously lost cause. In 1920, the AMXs House of Del­ egates approved a resolution condemning compulsory health insurance (Numbers, 1985). The main aim of this resolution was to solidify the medical profession against government interference with the practice of medicine.

Institutional and Public Opposition Compared to Europe, American institu­ tions were privately run. For example, American hospitals were mainly private, whereas in Europe they were largely gov­ ernment-operated facilities (Starr, 1982).

Anderson ( 1990) pointed to five main players in the private arena that viewed compulsory health insurance as encroach­ ing on their interests. ( 1) Members of the medical profession saw erosion of their earnings as the primary source of their income would shift from individual patients to the government. (2) The insur­ ance industry feared losing the income it derived from disability insurance, some insurance against medical services, and funeral benefits.2 (3) The pharmaceutical

industry feared the government would curtail its profits by acting as a monopoly buyer, and retail pharmacists feared that hospitals would establish their own phar­ macies under a government-run national health care program. ( 4) Employers also saw the proposals as contrary to their interests. Spokespersons for U.S. business rejected the argument that national health insurance would add to productivity and efficiency. (5) It may seem ironic, but the labor unions-the American Federation of Labor, in particular-also denounced compulsory health insurance at the time. Union leaders were afraid the government would l:!Surp their own legitimate role of providing social benefits, thereby weaken­ ing the unions' influence in the workplace. Organized labor was the largest and most powerful interest group at that time, and its lack of support is considered instru­ mental in the defeat of national health insurance. John Murray (2007), an eco­ nomic historian, proposed that while most historians have focused on the private entities just discussed, it is notable that the typical voter was not clamoring for some sort of government health insurance. To the contrary, whenever government-pro­ vided insurance programs were put on ref­ erendum ballots, they were resoundingly defeated.

ldeolog�cal Differences In the American experience, individualism and self-determination, distrust of govern­ ment, and reliance on the private sector to address social concerns-collectively seen

2 Patients admitted to a hospital were required to pay a burial deposit so the hospital would not have to incur a funeral expense if they died (Raffel and Raffel, 1994). Therefore, many people bought funeral policies from insurance companies.

as typical American values-have stood as a bulwark against anything perceived as an attack on individual liberties. These beliefs and values have typically represented the sentiments of the American middle class, whose support was necessary for any broad-based health care reform. Con - versely, during times of national distress, such as the Great Depression, pure neces­ sity may have legitimized the advance­ ment of social programs, such as the New Deal programs of the Franklin Roosevelt era (e.g., Social Security legislation pro­ viding old-age pensions and unemploy­ ment compensation).

In the early 1940s, during Roosevelt's presidency, several bills on national health insurance were introduced in Congress, but they all failed to pass. Perhaps the most notable bill was the Wagner-Murray­ Dingell bill, drafted in 1943 and named after the bill's congressional sponsors. World War II diverted the nation's atten­ tion to other issues, however, and without the president's active support the bill died quietly (Numbers, 1985).

In 1946, ;E-Iarry Truman became the first president to make an appeal for a national health care program (Anderson, 1990). Unlike the Progressives, who had proposed a plan for the working class, Truman proposed a single health insur­ ance plan that would include all classes of society. At the president's behest, the Wagner-Murray-Dingell bill was redrafted and reintroduced. The AMA was vehe­ ment in opposing the plan. Other inte!est groups, such as the AHA, also opposed it. By this time, private health insurance had expanded. Initial public reaction to the

Medical Services in the Postindustrial Era 133

Wagner-Murray-Dingell bill was positive; however, when a government-controlled medical plan was compared to private insurance, polls showed that only 12 % of the public favored extending Social Secu­ rity to include health insurance (Numbers, 1985).

During this era of the Cold War, 3 any attempts to introduce national health insurance were met with the stigmatizing label of socialized medicine-a label that has since become synonymous with any large-scale government-sponsored expansion of health insurance or intru­ sion in the private practice of medicine. The Republicans took control of Con­ gress in 1946, and any interest in enact­ ing national health insurance was put to rest. However, to the surprise of many, Truman was reelected in 1948, and he promised to establish a national health insurance system if the Democrats were returned to power (Starr, 1982). Fearing the inevitable, the AMA levied a $25 fee on each of its members to build a war chest of $3.5 million (Anderson, 1990), which was a substantial sum of money at the time. The AMA hired the public relations firm of W hitaker and Baxter and spent $1.5 million in 1949 alone, as it launched one of the most expensive lob­ bying efforts in American history. This campaign directly linked national health insurance with Communism so that the idea of "socialized medicine" was firmly implanted in the public's minds. In 1952, the election of a Republican president, Dwight Eisenhower, effectively ended any further debate over national health insurance.

3 Rivalry and hostility after World War II between the United States and the former Soviet Union.

134 Chapter 3 Th e Evol ution of Hea lth Services in the U n ited States

Tax Aversion Americans have generally supported the idea that the government ought to help people who are in financial need to pay for their medical care. However, most Ameri­ cans have not favored an increase in their own taxes to pay for such care. This reluc­ tance is perhaps why health care reform failed in 199 3.

While seeking the presidency in 1991, then Governor Bill Clinton made health care reform a major campaign issue. Not since Harry Truman's initiatives in the 1940s had such a bold attempt to overhaul the U.S. health care system been made by a presidential candidate. In the Pennsyl­ vania U.S. Senate election in November 1991, Democrat Harris Wofford had won while his call for national health insurance was widely supported by middle-class Pennsylvanians. Various public polls also seemed to suggest that the rising cost of health care was a concern for many peo­ ple. These developments signaled that the time for national health insurance might be ripe.

After taking office in 1992, President Clinton made health care reform a top pri­ ority. His wife, Hillary Clinton, was given the leadership role for the Task Force on National Health Reform. A complex piece of legislation, the Health Security Act, was introduced in November 1993, but within the first year it died in Congress.

Some of the fundamental causes of the failure of the Clinton plan were no doubt historical in nature, as discussed previ­ ously in this chapter. According to one seasoned political observer, James J. Mon­ gan (1995), the reform debate in Congress was not about the expansion of health insurance, but rather about the financing of the proposed services. Avoiding tax

increases, it appeared, took priority over expanding health insurance coverage and caused the demise of Clinton's health care reform initiatives.

Creation of Medicare and Medicaid The year 1965 marked a rnaj or turning point in U.S. health policy. Up to this point, employer-sponsored private health insur­ ance was the only widely available source of payment for health care, and it was available primarily to middle-class work­ ing Americans and their families. Many of the elderly, the unemployed, and the poor had to rely on their own resources, on limited public programs, or on charity from hospitals and individual physicians. Often, when charity care was provided, private payers were charged more to make up the difference, a practice referred to as cost shifting or cross-subsidization. ·In 1965, however, Congress passed the amendments to the Social Security Act and created the Medicare and Medicaid programs. Thus, for the first time in U.S. history, the government assumed direct responsibility for paying for health care on behalf of two vulnerable population groups-the elderly and the poor (Potter and Longest, 1994).

During earlier debates over national health ins�rance, one thing had become clear: Government intervention was not desired by most Americans, but the pub­ lic would not oppose reform initiatives to help the underprivileged and vulnerable classes, such as the poor and the elderly. On their own, most of the poor and the elderly could not afford the increas­ ing costs of health care. Also, because the health status of these groups was

programs, plan new strategies, mea­ sure progress, and discontinue inef­ fective services.

� Basic Conce.pts of Health

Health In the United States, the concepts of health and health care have largely been governed by the medical model, more specifically ref erred to as the biomedi �

cal model. The medical model defines health as the absence of illness or disease. This definition implies that optimal health exists when a person is free of symptoms and does not require medical treatment. However, it is not a definition of health in the true sense. This prevailing view of health emphasizes clinical diagnoses and medical interventions to treat disease or symptoms of disease, but fails to account for prevention of disease and health pro­ motion. Therefore, when the term ((health care delivery" is used, in reality it refers to medical care delivery.

Medical sociologists have gone a step further in defining health as the state of optimal capacity of an individual to per­ form his or her expected social roles and tasks, such as work, school, and household chores (Parsons, 1972). A person who is unable (as opposed to unwilling) to per­ form his or her social roles in society is considered sick. However, this concept also seems inadequate, because many peo­ ple continue to engage in their social obli­ gations despite suffering from pain, cough, colds, and other types of temporary dis­ abilities, including mental distress. Their efforts are counterbalanced by individuals

Basic Concepts of Health 53

who shirk their social responsibilities even when they may be in good health. In other words, optimal health is not necessar­ ily reflected in a person's engagement in social roles and responsibilities.

An emphasis on both the physical and mental dimensions of health is found in the definition of health proposed by the Society for Academic Emergency Medicine. According to this organization, health is ((a state of physical and mental well-being that facilitates the achievement of individual and societal goals" (Ethics Committee, Society for Academic Emer­ gency Medicine, 1992). This view of health recognizes the importance of achieving harmony between the physiological and emotional dimensions.

The definition of health developed by the World Health Organization (WHO) ·

is most often cited as the ideal for health care delivery systems; it recognizes that optimal health is more than the absence of disease or infirmity. The _WHO (1948) defines health as ((a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity:' As a biopsychosocial model, the WHO's definition specifically identifies social well-being as a third dimension of health. For example, having a social sup­ port network is positively associated with resilience to life stresses, self-esteem, and social relations. Conversely, many stud­ ies show that social isolation is associated with a higher risk of poor health and mor­ tality (Pantell et al., 2013).

The WHO has also defined a health care system as all the activities whose pri­ mary purpose is to promote, restore, or maintain health (McKee, 2001). As this chapter points out, health care should include much more than medical care.

I I

84 Chapter 2 Beliefs, Values, and Health

FORMULA 2·16

Average length of stay= Total number of

inpatient days during a given time period/

Total number of patients served during the

same time period

Measures of Global Health Global monitoring of changes in the health of various populations requires the use of "tried and true" global health indicators. Global health indicators can be divided into those that directly mea­ sure health phenomena (e.g., diseases, deaths, use of services) and indirect mea­ sures (e.g., social development, education and poverty indicators); these are also referred to as proximal and distal indica­ tors, respectively. As one example, when using population statistics to describe lev­ els of educational attainment and access to safe water and sanitation, it is possible to accurately categorize a country as hav­ ing a population with high, medium, or low burden of disease (Larson and Mer­ cer, 2004).

The WHO (2015) compiles more than 100 indicators of a broad range of key public health issues. Commonly used indicators of life expectancy and mortality include life expectancy at age 60, healthy life expectancy at birth, infant and under-5 mortality rates, and the adult mortality rate. Cause-specific mortality rates are collected for selected communicable and noncommunicable diseases. Health ser­ vices indicators reflect the extent to which people receive important health interven­ tions. These services include unmet needs for family planning, prenatal care cover­ age, births attended by skilled health per­ sonnel, vaccination coverage, and other

prevention and treatment coverage for common diseases among children. It is also important to report indicators of risk factors that are associated with increased mortality and morbidity. To assess the risk of transmission of diarrheal disease, for example, it is important to know what per­ centage of the population does not have safe water supplies and sanitation. Simi­ larly, use of solid fuels in households is a proxy indicator for household pollution. Indicators of the prevalence of diabetes, hypertension, and obesity all signal the risk of cardiovascular disease and several types of cancer.

Indirect indicators of global health include health system indicators related to the workforce, infrastructure, medical technologies and devices, and government expenditures on health. Demographic and socioeconomic factors that are major deter­ minants of health include primary school enrollment, population living in poverty, population size, crude birth and death rates, total fertility rates, and percapita gross national income.

� Anthro-Cultural Beliefs and Values

A value system orients the members of a society toward defining what is desir­ able for that society. It has been observed that

' even a society as complex and highly

diverse as that found in the United States can be said to have a relatively well­ integrated system of institutionalized common values at the societal level (Par-

·

sons, 1972). Although such a view still prevails, American society now includes distinct subcultures whose membership

has increased significantly due to a steady influx of immigrants from different parts

of the world. The current system of health ser­

vices delivery has its roots in the tradi­ tional beliefs and values espoused by the American people. This belief and value system governs the training and gen - eral orientation of health care providers, the type of health delivery settings, the financing and allocation of resources, and

access to health care in the United States. Among the main beliefs and values preva­ lent in the American culture are those outlined here.

1. The United States has a strong belief in the advancement of science and the application of scientific methods to medicine. This belief was instrumental in the creation of the medical model that primarily governs U.S. health care delivery. As a result, the United States has long led the world in medical break­ throughs. These developments have had numerous implications for health services delivery: a. They increase the demand

for the latest treatments and raise patients' expectations for finding cures.

b. Because medical profession­ als focus on clinical interven­ tions, they do not provide adequate emphasis on the holistic aspects of health and use of alternative therapies.

c. Health care professionals have been trained to. focus on physical symptoms rather than the underlying causes of disease.

Anthro-Cultural Beliefs and Values 85

d. Integrating diagnosis and treatment with disease pre­ vention has lagged behind other concerns.

e. Most research efforts have focused on the develop­ ment of medical technology. Fewer resources have been committed to the preserva­ tion and enhancement of health and well-being.

f. Medical specialists, using the latest technologies, are held in higher esteem and earn higher incomes than do gen­ eral practitioners.

g. The desirability of health care delivery institutions such as hospitals is often evaluated based on their acquisition of advanced technology.

h. Whereas biomedicine has taken central stage in the biomedical model, mental health diagnosis and treat­ ment have been relegated to a lesser status.

i. The biomedical model has neglected the social and spiritual elements of health.

2. The United States has been a champion of capitalism. Due to the public's strong belief in capi­ talism, health care has largely been viewed as an economic good (or service), not as a pub­ lic resource.

3. A culture of capitalism promotes entrepreneurial spirit and self­ determination. Hence, individ­ ual capabilities to obtain health services have largely determined the production and consumption

86 Chapter 2 Beliefs, Values, and Health

of health care (i.e., which services will be produced, where and in which quantities, and who will have access to those services). Some key implications are as follows: a. Upper-tier access to health

care services is available mainly through private health insur­ ance. Those with public insur­ ance fall in a second tier. The uninsured make up a third tier.

b. A clear distinction exists between the types of ser­ vices for poor and affluent communities, and between the types of services avail­ able in rural and inner-city locations.

c. The culture of individual­ ism emphasizes individual health rather than popula­ tion health. Consequently, medical practice has been directed at keeping the indi­ vidual healthy, rather than the entire community.

d. A concern for the most underprivileged classes in society-the poor, elderly, disabled, and children-led to the creation of the public programs Medicaid, Medi­ care, and the Children's Health Insurance Program (CHIP).

4. U.S. health care delivery is guided by principles of free enterprise and a general dis­ trust of big government. Hence, health care delivery is largely in private hands, and a separation

exists between public health functions and the private prac­ tice of medicine.

Equitable Distribution of Health Care Scarcity of economic resources is a central economic concept. From this perspective, health care can be viewed as an economic good. Two fundamental questions arise with regard to how scarce health care resources ought to be used:

• How much health care should be produced?

• How should health care be distributed?

The first question concerns the appropri­ ate combination of health services that should be produced in relation to all other goods and services in the overall economy. If more health care is produced, a society may concomitantly devote fewer resources to producing some other goods, such as food, clothing, and transportation. The second question affects individuals at a more personal level-namely, it deals with who can receive which type of medical services, and how access to services will be restricted.

The production, distribution, and sub­ sequent consumption of health care must be perceived as equitable by a society. No society has found a perfectly equitable method to distribute limited economic resources. In fact, any method of resource distribution inevitably leaves some inequal­ ities in its wake. Therefore, societies try to allocate resources according to some guid­ ing principles that are deemed acceptable by the particular society. Such principles are ingrained in a society's value and belief system. It is recognized, for example, that

132 Chapter 3 The Evol ution of H ealth Services i n the U n ited States

blow to the national health insurance movement, as anti-German feelings were aroused among the U.S. populace. The U.S. government denounced German social insurance, and opponents of health insur­ ance called it a Prussian menace, inconsis­ tent with American values (Starr, 1982).

After attempts to pass compulsory health insurance laws failed at the state levels in California and New York, AALL itself lost interest in an obviously lost cause. In 1920, the AMXs House of Del­ egates approved a resolution condemning compulsory health insurance (Numbers, 1985). The main aim of this resolution was to solidify the medical profession against government interference with the practice of medicine.

Institutional and Public Opposition Compared to Europe, American institu­ tions were privately run. For example, American hospitals were mainly private, whereas in Europe they were largely gov­ ernment-operated facilities (Starr, 1982).

Anderson ( 1990) pointed to five main players in the private arena that viewed compulsory health insurance as encroach­ ing on their interests. ( 1) Members of the medical profession saw erosion of their earnings as the primary source of their income would shift from individual patients to the government. (2) The insur­ ance industry feared losing the income it derived from disability insurance, some insurance against medical services, and funeral benefits.2 (3) The pharmaceutical

industry feared the government would curtail its profits by acting as a monopoly buyer, and retail pharmacists feared that hospitals would establish their own phar­ macies under a government-run national health care program. ( 4) Employers also saw the proposals as contrary to their interests. Spokespersons for U.S. business rejected the argument that national health insurance would add to productivity and efficiency. (5) It may seem ironic, but the labor unions-the American Federation of Labor, in particular-also denounced compulsory health insurance at the time. Union leaders were afraid the government would l:!Surp their own legitimate role of providing social benefits, thereby weaken­ ing the unions' influence in the workplace. Organized labor was the largest and most powerful interest group at that time, and its lack of support is considered instru­ mental in the defeat of national health insurance. John Murray (2007), an eco­ nomic historian, proposed that while most historians have focused on the private entities just discussed, it is notable that the typical voter was not clamoring for some sort of government health insurance. To the contrary, whenever government-pro­ vided insurance programs were put on ref­ erendum ballots, they were resoundingly defeated.

ldeolog�cal Differences In the American experience, individualism and self-determination, distrust of govern­ ment, and reliance on the private sector to address social concerns-collectively seen

2 Patients admitted to a hospital were required to pay a burial deposit so the hospital would not have to incur a funeral expense if they died (Raffel and Raffel, 1994). Therefore, many people bought funeral policies from insurance companies.

as typical American values-have stood as a bulwark against anything perceived as an attack on individual liberties. These beliefs and values have typically represented the sentiments of the American middle class, whose support was necessary for any broad-based health care reform. Con - versely, during times of national distress, such as the Great Depression, pure neces­ sity may have legitimized the advance­ ment of social programs, such as the New Deal programs of the Franklin Roosevelt era (e.g., Social Security legislation pro­ viding old-age pensions and unemploy­ ment compensation).

In the early 1940s, during Roosevelt's presidency, several bills on national health insurance were introduced in Congress, but they all failed to pass. Perhaps the most notable bill was the Wagner-Murray­ Dingell bill, drafted in 1943 and named after the bill's congressional sponsors. World War II diverted the nation's atten­ tion to other issues, however, and without the president's active support the bill died quietly (Numbers, 1985).

In 1946, ;E-Iarry Truman became the first president to make an appeal for a national health care program (Anderson, 1990). Unlike the Progressives, who had proposed a plan for the working class, Truman proposed a single health insur­ ance plan that would include all classes of society. At the president's behest, the Wagner-Murray-Dingell bill was redrafted and reintroduced. The AMA was vehe­ ment in opposing the plan. Other inte!est groups, such as the AHA, also opposed it. By this time, private health insurance had expanded. Initial public reaction to the

Medical Services in the Postindustrial Era 133

Wagner-Murray-Dingell bill was positive; however, when a government-controlled medical plan was compared to private insurance, polls showed that only 12 % of the public favored extending Social Secu­ rity to include health insurance (Numbers, 1985).

During this era of the Cold War, 3 any attempts to introduce national health insurance were met with the stigmatizing label of socialized medicine-a label that has since become synonymous with any large-scale government-sponsored expansion of health insurance or intru­ sion in the private practice of medicine. The Republicans took control of Con­ gress in 1946, and any interest in enact­ ing national health insurance was put to rest. However, to the surprise of many, Truman was reelected in 1948, and he promised to establish a national health insurance system if the Democrats were returned to power (Starr, 1982). Fearing the inevitable, the AMA levied a $25 fee on each of its members to build a war chest of $3.5 million (Anderson, 1990), which was a substantial sum of money at the time. The AMA hired the public relations firm of W hitaker and Baxter and spent $1.5 million in 1949 alone, as it launched one of the most expensive lob­ bying efforts in American history. This campaign directly linked national health insurance with Communism so that the idea of "socialized medicine" was firmly implanted in the public's minds. In 1952, the election of a Republican president, Dwight Eisenhower, effectively ended any further debate over national health insurance.

3 Rivalry and hostility after World War II between the United States and the former Soviet Union.

134 Chapter 3 Th e Evol ution of Hea lth Services in the U n ited States

Tax Aversion Americans have generally supported the idea that the government ought to help people who are in financial need to pay for their medical care. However, most Ameri­ cans have not favored an increase in their own taxes to pay for such care. This reluc­ tance is perhaps why health care reform failed in 199 3.

While seeking the presidency in 1991, then Governor Bill Clinton made health care reform a major campaign issue. Not since Harry Truman's initiatives in the 1940s had such a bold attempt to overhaul the U.S. health care system been made by a presidential candidate. In the Pennsyl­ vania U.S. Senate election in November 1991, Democrat Harris Wofford had won while his call for national health insurance was widely supported by middle-class Pennsylvanians. Various public polls also seemed to suggest that the rising cost of health care was a concern for many peo­ ple. These developments signaled that the time for national health insurance might be ripe.

After taking office in 1992, President Clinton made health care reform a top pri­ ority. His wife, Hillary Clinton, was given the leadership role for the Task Force on National Health Reform. A complex piece of legislation, the Health Security Act, was introduced in November 1993, but within the first year it died in Congress.

Some of the fundamental causes of the failure of the Clinton plan were no doubt historical in nature, as discussed previ­ ously in this chapter. According to one seasoned political observer, James J. Mon­ gan (1995), the reform debate in Congress was not about the expansion of health insurance, but rather about the financing of the proposed services. Avoiding tax

increases, it appeared, took priority over expanding health insurance coverage and caused the demise of Clinton's health care reform initiatives.

Creation of Medicare and Medicaid The year 1965 marked a rnaj or turning point in U.S. health policy. Up to this point, employer-sponsored private health insur­ ance was the only widely available source of payment for health care, and it was available primarily to middle-class work­ ing Americans and their families. Many of the elderly, the unemployed, and the poor had to rely on their own resources, on limited public programs, or on charity from hospitals and individual physicians. Often, when charity care was provided, private payers were charged more to make up the difference, a practice referred to as cost shifting or cross-subsidization. ·In 1965, however, Congress passed the amendments to the Social Security Act and created the Medicare and Medicaid programs. Thus, for the first time in U.S. history, the government assumed direct responsibility for paying for health care on behalf of two vulnerable population groups-the elderly and the poor (Potter and Longest, 1994).

During earlier debates over national health ins�rance, one thing had become clear: Government intervention was not desired by most Americans, but the pub­ lic would not oppose reform initiatives to help the underprivileged and vulnerable classes, such as the poor and the elderly. On their own, most of the poor and the elderly could not afford the increas­ ing costs of health care. Also, because the health status of these groups was