Lecture Twelve: Progressive Reform and Occupational Medicine

The Boundaries and Scope of American Medicine, 1909-1930

The American Medical Contract: State Expectations vs. State Services

The Control of Medical Need

"The real need for medical care is a medical, not an economic, concept....It can be defined only in terms of the physical conditions of the people and the capacities of science and the art of medicine to deal with them.  Thus, it is not always a conscious need, still less an active desire backed by a willingness to pay.  The ordinary layman lacks the knowledge to define his own medical needs and can rely only on the expert opinion of medical practitioners and public health authorities." -- Committee on the Costs of Medical Care, 1933

Medical Costs: Part One

1. W.W. Mayo, c. 1880: What it's worth to you
   • Political radical; medical need a social good
2. W. and C. Mayo: Free to medical, to educators, no mortgages, no suits
   • 1920: social service department to determine capacity to pay
   • 25% free; 30% at cost; 45% at cost +
3. c. 1928: Average operation: $1,000; Childbirth: $1,000

Toward Health Insurance

1. Four problems of sickness
   • Medical costs
   • Lost wages
   • Costs to business
   • Costs to the state
2. European precedents
3. 1883: German health insurance
4. also Austria, Hungary, Norway, Netherlands, Britain [1911], Russia
5. For workers only!

American precedents

1. Sailors - ins
2. Military
3. Poor
4. Miners - ins
5. Friendly societies and unions - ins
   • Granite cutters, 1877
6. Burial insurance - ins

Problems with Health Insurance

1. Sick people only vs. cherry picking - the need for well-defined group
2. American Association for Labor Legislation - AMA, 1914-1915
   • AMA Concerns: capitation, public health, group practice
3. Opposition
   • American Federation of Labor (Gompers) Union vs. State
   • Industry (invest in public health)

Changes in the Health Problem, 1920-1940

1. Rising hospital costs
2. Rising variability in family medical costs
3. The Depression; need for stable hospital budgets
4. Blue Cross, Dallas, 1929: from one hospital to many (RR, mining, lumber antecedents)
5. AMA support for voluntary prepayment, after opposition, 1934-1938 (preference for money payments, not guaranteed service)
6. 1948: inclusion of health insurance in collective bargaining

Medical Costs: Part Two

1. Mid-1920s
   • Family income: $1,500-1,800; ME=$68
   • Family income: $1,800-2,100; ME=$74
   • Family income: $2,100-2,500; ME=$82
2. Lewis Dublin, 1928

Opposition to Health Insurance

1. 1934-1935: Social Security (without health care)
2. Opposition:
   • "Solicitation of patients, destructive competition among professional groups, inferior medical service, loss of personal relationship between patient and physician, and demoralization of the profession." -- from Numbers, 3rd Party
3. 1943: Wagner-Dingell Bill; and opposition to federal control
4. 1948: Opposition to Truman proposals: voluntary insurance as the doctor's friend
   • "Socialized medicine is the keystone to the arch of the socialist state." -- Lenin

The Coming of the Golden Cow

1. After three strikes
2. National Health Insurance?
   • 1914-1919, 1934-1935, 1943-1949
3. Medicare and Medicaid, 1965