Bitter medicine: Why health care is a privilege, not a right, in America

Tom Gallagher, San Francisco Bay Guardian, June 25, 2003 (Vol. 37, No. 39)

As VI Lenin, the leader of the Russian Revolution, wrote, "Socialized Medicine is the keystone to the arch of the Socialist State." Actually, Lenin didn't write that, but the American Medical Association figured he might as well have, so it made up the quote for him and used it in its anti-national health insurance literature of the late 1940s. Such were the politics of health care in the 20th-century United States. Since those politics resulted in our nation's ending the century as the world's only wealthy democracy without a national health insurance system, much of Colin Gordon's Dead on Arrival: The Politics of Health Care in Twentieth-Century America is the story of how the opponents kept it that way.

Certainly the fact that "the AMA ... was largely successful in making health policy a theater of the cold war" was important, but the campaign predated that. When World War I-era reformers suggested that the nearly one-in-three rate at which enlistees failed military physicals showed the need to guarantee Americans adequate health care, the status quo's defenders denounced the idea as "a dangerous device, invented in Germany, announced by the German emperor from the throne the same year he started plotting and preparing to conquer the world." One called it a "paternalistic" system like those found in "king-ridden Europe."

Then along came the Russian Revolution, and kings and emperors were no longer the big problem. For much of the next half century, national health insurance was dealt with as a step on the road to godless communism, although there were still interruptions: With the rise of Adolf Hitler, a Kentucky medical society declared that national health insurance would "make the Surgeon General of the United States a medical dictator ... as much so as a Nazi dictator." And the Oklahoma Medical Society believed the Holocaust "could never have happened if Bismarck had not clandestinely murdered the free spirit of medicine [with] ... compulsory health insurance." Lest any of the critiques appear contradictory, the AMA synthesized it all in 1946, explaining that a national system was a "red fascist" idea, a product of "German-Japanese-Russian philosophy." In other words, everything bad rolled into one.

All of this might be funnier were the problem of lack of access to health care in the United States not so serious. How serious? Well, we do know that ours is the only industrialized nation without a national system, but we don't actually know the number of people without insurance. The last census said there were 41 million such people, but the Congressional Budget Office has just declared that the truth actually lies somewhere on both sides of that figure, suggesting that 21 million to 31 million were uninsured for the entirety of 1998, the last year for which reliable figures are available, while 57 million to 59 million, "about a quarter of the non-elderly population," were uninsured for some part of that year. The fact that the Republican chair of the House Ways and Means Committee greeted this assessment as good news is a fair measure of the magnitude of the problem.

For 50 years US health care has been dominated by what Gordon calls the "private welfare state" – the distinctive US reliance on employment-based health insurance that mushroomed from covering fewer than a half-million people in 1946 to nearly 30 million in 1954. As Gordon, who teaches history at the University of Iowa, describes it, the system "grew in response to the threat and reality of unionization," which was at its peak during the post-World War II years.

Among the system's problems is its tendency to magnify already existing inequities of employment – in other words, better jobs tend to bring more and better coverage. So when the rate of civilian-employee health coverage dropped from 61 percent to 54 percent in the 1980s and early 1990s, for low-wage workers it fell from 30 percent to 14 percent. And while overall private health insurance coverage (the self-insured included) stood at about 70 percent at the end of the century, the rate for African Americans was only 51 percent, and for Latinos it was just over 40 percent. And women have always fared worse than men. Nonetheless, all subsequent efforts to broaden coverage have started with the assumption of the private system as a base.

The last significant change – the 1965 Johnson administration Great Society programs – did not touch this base: Medicare "recipients" were elderly and Medicaid "beneficiaries" were poor. Meanwhile, unions may have been responsible for the spread of the employee health insurance system, but for the most part businesses controlled it, which meant that some corporate giants got into the health care picture. This, in turn, insured that some would try to control the health care industry. Not a task easily accomplished, but, according to Gordon, "by the end of 1990s, HMOs and their variants claimed nearly 80 percent of the health insurance market." And with so many doctors functioning under health maintenance organizations, the AMA no longer dominated the debate.

Cost cutting was never the prime concern of the AMA nor of the doctor-controlled Blue Cross and Blue Shield system that had dominated the early health insurance scene. But "between 1965 and 1990, health costs swelled from 6 to nearly 15 percent of GDP," and corporate America wanted to figure out how to cut its costs. So when the Clinton administration proposed major health care reform in 1993, it took as givens two contradictory elements: the need to reduce costs and the need to leave the system of private health insurance in place. Logically, US corporate cost cutters ought to be for dumping the thicket of health insurance bureaucracies, private and public, not borne by foreign countries and competitors. Instead, corporate America has viewed an attack on one of its sectors as an attack on all and has refused to let private health insurance go the way of the blacksmithing industry. This commitment to preserve the health insurance industry meant that when the Clinton Plan finally appeared, "at 1,342 pages it was 1,340 pages longer than the Canada Health Plan." The Canada Health Plan guaranteed Canadians health care; the Clinton Plan resembled nothing as much as the cartoons of the late Rube Goldberg that showed preposterously complicated machines performing the simplest of tasks.

Gordon's book is not for the casual reader, but it is a treasure trove of information for anyone seriously wishing to tackle this issue, which Gordon sees as "a compelling public concern for the new century." Unlike in the last couple of election campaigns, the idea of universal health care coverage is again in play in the Democratic primaries, with at least Rep. Dennis Kucinich supporting it. At the same time we're watching a government relatively ill organized for social services but superbly organized for war act with increasing confidence as to the superiority of its system for the entire world. On balance Gordon seems on solid ground in concluding that national coverage will remain "an elusive political target."

Tom Gallagher is a writer who lives in San Francisco.

Dead on Arrival: The Politics of Health Care in Twentieth-Century America
By Colin Gordon. Princeton University Press, 316 pages, $29.95.

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