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tv   Health Care Policy Since World War I  CSPAN  September 1, 2019 4:50pm-6:01pm EDT

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care policy since world war i. topics include the roots of the modern health-care system, the medical field's transformation into a business, and disparities in insurance coverage. the natural history center hosted this event. mr. kennedy: i think we are going to try to start this event on time. my name is dane kennedy, i am director of the national history center. i want to welcome you all to this briefing on the history of u.s. health care, health care policy. this is a briefing sponsored by the national history center, which is affiliated with the american historical association, and is part of a series of briefings that we offer that provide historical perspectives to issues that are currently confronting congress. we will have another one at the end of next month, which will be on the history of u.s.-iranian relations. i should stress that these
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events are strictly nonpartisan, they are not intended to offer any kind of policy recommendations or agendas. they are simply meant to give greater insight into how we got to where we are, which we believe helps us to understand how we can solve problems. so a few thanks, and then i will turn it over to alan. first of all, the mellon foundation funds this program. we are very grateful to them. secondly, the room has been booked for us by congressman jerry connolly's office, and we are grateful to them. finally, i want to thank my reiger,t director, jeff who is at the table outside but will be coming in shortly. now i will turn it over to professor alan kraut from the american university, who will moderate the event. before i do, let me say, most of you will find these index cards on your seat.
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the intent of these is that as the discussion proceeds, if you have questions, write them on these cards. we will collect them after formal remarks and use them to initiate the discussion. think about that as they are giving their remarks. alan? alan: thank you, dane. good morning. in 1941, the influential publisher henry louis declared that in his view, the 20th century would be the american century, a time when american achievements and influence would outdistance those of other countries. in no field was that more accurate than in the medical sciences, in discovery and research and vaccine development, and surgical innovation, the united states was and remains dominant, much as france, england, and germany had been in the medical vanguard in an earlier era. medical heroes abounded.
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the conquerors of polio, dr. jonas salk. a heart surgeon performed the first coronary bypass operation in 1964. thomas starzl, sometimes called the father of modern transplantation, performed the first human liver transplant in 1963. and then there was the miraculous benefits of the human genome project at the national institutes of health. the problem is that the wondrous results produced by american researchers, surgeons, epidemic fighters was not always accessible by the american population broadly and equitably. too often, health care in the united states was among the privileges enjoyed by the wealthy or postwar americans who had access to good health insurance policies, many purchased in the workplace. after the birth of the blues in the midcentury, and of course, i
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mean blue cross and blue shield, labor unions and private employers negotiated excellent medical plans for their employees. however, as the cost of medical care escalated, the number of middle-class americans who could afford good health insurance declined. many employers prefer to negotiate salaries with employees, but not medical benefits, because of climbing costs. increasingly, many in the middle class joined the poor in their deprivation of good health care. by 2008, 44.2 million americans were without health insurance, 17% of the population. the affordable care act reduced that to just below 27 million in 2016. broadening the ability of americans to access quality health care has not been easy because unlike many other
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countries throughout the world, the government of the united states long remained distant from caring for individuals not in the uniform of the united states military. there were exceptions, such as the care of seamen in the marine hospitals established in 1798 legislation signed by president john adams, or the medical attention rendered to civilians by the short-lived freedmen's bureau after the civil war. however, for the most part, congress has resisted initiative s to involve the government and -- government in offering health care or insurance to any but the military. few americans realize that it was the vociferous republican progressive theodore roosevelt who was the first to unsuccessfully but passionately advocate for national health insurance in the first decade of the 20th century. later, his cousin franklin, a democrat, and later still, harry truman, lyndon johnson, and bill clinton pursued a role for the federal government in providing
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health care to all americans. johnson's medicare and medicaid offered some relief to vulnerable populations, but not until the obama administration did the federal government offer a fresh path to relieving the anxieties of those shut out of health insurance and the health insurance market. however, many issues remain. so where are we now? how can history help us? the united states of america, the richest and most medically accomplished country in the -- on the globe, has still to solve many problems. the american population suffers from some of the highest health care costs on the planet. according to 2017 estimates, we spend $3.5 trillion every year, around 17.9% of the gdp, and about $10,739 each year in
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health care costs per person. but it is doubtful whether this high expenditure translates into improved patient care and health care outcomes. the commonwealth fund's 2018 study of 11 countries, including australia, canada, france, the netherlands, germany, norway, sweden, switzerland, and the u.k., found that the u.s. ranked last for health outcomes. equity and quality, despite having the highest per capita health earnings, last. the study also found that more americans die from poor care quality than the citizens of any other country involved in the study. also, poor access to primary care in the u.s. has contributed to inadequate chronic disease prevention and management. delayed diagnoses and safety concerns, among other issues. much of the care accessed by
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americans is inadequate to their need. prices of pharmaceuticals are sky high as compared to other countries, especially for life-saving drugs such as insulin. the population of the country remains underinsured as of the -- as the political debates of different approaches sizzle in the prelude to the next election. everything has a history. that's our motto at the national history center. everything has a history. and before we can get to a better place, we need to understand how we came to this and why we find it so difficult to get the american population to a better place with respect to health care, as so many other countries have done. fortunately, we have two superb historians with us this morning who can lead us through that tangle that has been the history of health care in the united states. we need to know that past before
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we can intelligently navigate successfully through the rough waters of social and political debate that lay ahead. our first speaker this morning is professor nancy tomes, state -- cuny state university of new york distinguished professor at stony brook university. she is the author of four books. a generous confidence, the art of aside them keeping, published in 1984. madness in america, cultural and medical perceptions of mental illness before 1914. a co-authored work. the gospel of germs, men, women and life. and most recently, how madison avenue and modern medicine turned patients into consumers, 2016. for the gospel of germs, professor tomes won both the
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american association for the history of medicine's medal in -- and the history of science society prize. the american public health association awarded her an award for her distinguished body of scholarship in the history of public health, and most recently in 2017, she received the very prestigious bancroft prize for distinguished work in american history, for remaking the american patient. our second speaker this morning beatrix hoffman who teaches a northern illinois university where she is a heinz teaching undergraduate in humanities. she is the author of two books on the health care system, the wages of sickness: the politics of health insurance in progressive america, 2000 one, and health care for some, rights in the united states. as well as a co-edited volume .ith professor tomes
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she published many articles dealing with aspects of the health-care system from the history of emergency room's to the origins of copayments and deductibles. her work has been supported by fornational endowment humanities, the robert wood johnson foundation and she received recognition in many ways. she gave the commencement address at loyola scripps school of medicine in chicago. it is with great pleasure that i introduce first professor tomes. nancy? >> thank you for that nice introduction. my task is to talk about a unique feature of u.s. health care, that we think of health care primarily as a commodity, a set of products and services that should and must be delivered according to market
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based principles. fee-for-service system, providers breakdown medical care and the component parts and charge for each product and service separately. at each stage of care, it is accepted and encouraged that someone will make a profit doing so. building a robust profit incentive into care supposedly drives the system to offer more and better care. since the ultimate purchaser of these services is the patient, better health as well as profit taking involves getting people to buy more health care products and services. as a result, medical care in the united states is embedded in our broader consumer culture, our custom of referring to patients as health care consumers and doctors as health care providers. why this point, some of you are likely thinking, of course.
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that is how modern medicine works. doesn't everyone think that way? in fact, no. advancedte other capitalist democracies and you discover they do not market ties health care to the extent the u.s. does, nor do they refer to patients as health care consumers. i get invited to speak abroad precisely because people in these other countries are curious about the consumeriffic care,of u.s. health chiefly to find out how to avoid it. upper the past two years, i spent a lot of time in the capitalist and pragmatic a nation as you will ever want to find. they are baffled by two particular traits of the american way of medicine. the aggressive use of marketing and advertising, and the resistance to giving all citizens help insurance. one of the most distinctive traits of american health care is its heavy reliance on sophisticated marketing and advertising. if you watch network tv, you are
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familiar with one such promotion advertisingnsumer of prescription drugs. new zealand is the only other country in the world that allows this kind of advertising. everywhere else, it is thought to be an inappropriate invasion of the doctor-patient relationship. in the u.s., even more money is spent on marketing and advertising to doctors. to influence their choice of what drugs and devices to prescribed for patients. companies compete fiercely to influence so-called physician preference items, which brand of death -- what brand of pacemaker a doctor chooses. a hefty chunk of money goes to advertising hospital chains and high-volume medical procedures. our european peers look at all of the money spent on marketing and advertising designed to promote the most new and expensive medicine, and say, no
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-- of course your health care costs more. it is no wonder you can't insure anyone. advanced biomedicine in other countries is expensive but somehow our capitalist peers managed to control the cost and provide almost universal access. when i visited the netherlands, their hospitals look exactly like ours, modern, up-to-date, high quality but with no advertising. all citizens are covered. my dutch friends are not worried about their health care and health insurance. it is hard to believe. most heartbreaking feature of the u.s. situation is how we spend more money per person, but do not seem to reap the commence or it benefits. -- commensurate benefits. if you are interested, we can provide links to more studies.
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why do we have this system, and how do we fix it? a lot of contemporary policy debate in the u.s. focuses on the role of the federal government. does the medical marketplace work badly because the government interferes too much or too little? as you ponder those questions, it is useful to turn back the clock. what was health care prior to 1965, the year the federal government got into the business of funding medical care to -- through medicare for seniors and medicaid for low income americans? today, i will provide a brief answer. i will show the downside of our heavily marketed system, inflationary prices, overuse of specialization, fragmentation of care and lack of access were evident by 1960, the first year the u.s. health-care system was declared to be in crisis. that crisis led to the federal
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government getting involved, ostensibly to correct for market failures. it did not work. the key take away point is this. policymakers who want to turn back the clock to some version of government free medicine need to look carefully at what the system was like before 1965, and why it did not work. why did the u.s. go the route of such a heavily marketized health care system? it is a long story. in the colonial era, guild regulation of medicine did not survive the transfer to the new world. settler colonialism encouraged the motto, every man his own doctors weregular the forerunners of today's physicians, they faced enormous competition from alternative
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healers. call yourself a doctor in the medical association couldn't do anything about it. faced competition from alternative healers. you could make drugs in a barrel and claimed they were a cure for cancer, and no fda was there to tell you no. there was concern that snake oil elixirs were hurting the american people. the medical profession was given powers to regulate itself and government got basic powers to require accurate labels on drugs. one of the reason to the end of medical freedom is the rise of more scientific medicine that yielded new diagnostic tools like the x-ray and new treatments, such as aseptic surgery. regular doctors, the ancestors of today's biomedicine, provided more effective goods and services to offer their patients. the icon of this new medicine was the hospital, which became
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known as the dr.'s workshop. in particular the surgical amphitheater, where germ-free, pain free surgery could now be performed. as the medical profession gained respect, it got more control over medical education and licensing, making it harder for alternative healers to compete. this new medicine required more education and technology. so it cost more. using a fee-for-service system, doctors began to pass costs onto the patient. there was no third-party system. the doctor gave you a bill and you paid it. as beatrix will explain, alternatives to fee-for-service medicine were proposed and defeated over and over in the 20th century. medical practice remained highly competitive and to do well, doctors had to be medical -- had to start wearing two hats, the medical professional and the modern businessmen. they sought to attract patients who could pay and started moving out of low income neighborhoods.
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they began to specialize, which allowed charging higher fees and the cost of medical care rose so much that after world war i, by 1926, patients were complaining about the high cost of keeping alive. the soaring cost of hospital care concerned people, setting the stage for a new product designed to provide security against health catastrophe, the private insurance policy. starting with ben franklin, americans have loved the concept of private insurance to hedge against bad luck and during the great depression, the insurance habit expanded to include hospital care finance through blue cross blue shield, a doctor-run nonprofit plan that allowed people to save toward future hospital bills. and the idea proved so popular, that by 1967, most americans had
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some kind of hospitalization insurance, mostly through their employer. this was insurance set up on a fee-for-service basis. hospitals and doctors said, here is what i charge, and that insurers paid the charge without question. after world war ii, as it's developed nation peers began to turn to more government regulation of health care costs and delivery, what we call socialized medicine, the united states doubled down on its privatized system, and in the early 1950's, the u.s. congress said no to national coverage. lots of taxpayer money to build more hospitals and fund medical research through the nih. this funding enabled scientists to innovate, hospitals to provide more care and create a health care system the u.s. could be proud of.
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in the midst of the cold war, democrats and republicans alike bought into the privatized approach. but there were flaws in this free enterprise approach that you don't need an advanced degree in economics to understand. in a consumer driven economy, consumer choice is supposed to drive competition that holds down prices and rewards excellence but the mechanism that allows consumer leverage in the marketplace do not work well in health care. medicine embodies an asymmetrical relationship. the doctor knows more than you do, and has special powers to direct your care. when it comes to the most effective treatment, the ones who could really save your life, the doctors have to order them for you. i cannot walk into a hospital and say, hook me up to an iv. medicine's professional ethics are supposed to prevent the doctor as businessman from overly ruling the doctor as --
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overruling the doctor as medical professional, and yet the way the american health care was market ties to made ethics harder and harder to enforce. between 1945 in 1965, the dynamics created a set of problem we still face. the privatized insurance system, incentivized providers to shift more care to the hospital, the most expensive venue. both doctors and hospitals charge higher prices, assuming patients had insurance to cover the costs. not all of them did. as pharmaceutical companies and medical device makers competed to offer doctors new products planned obsole sence became a byword in medicine and while encouraging innovation and high-tech care, the system set up a spiral and -- in costs. generalists who saw their patient saw incomes plummet and -- relative to specialists who did not.
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worries grew that the system promoted over use of city -- surgery and prescription drugs. significant groups of americans, the elderly and low income families in particular, lacked health insurance at all. by 1960, politicians and journalists began to use the word crisis to describe the american health care scene. the marketorrect failures of the american way of medicine, specifically the care of the elderly and low income, that the federal government finally got into the business of health care in 1965. to gain support for these programs, lyndon b. johnson agreed to set it up as a taxpayer-funded version of the private health care system with all the same built in triggers and over-specialization and incentives for more expensive care and a what the market will --r approach to price and it to pricing, worsening the spiral we see today.
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these are the problems we have been struggling to fix ever since. but there are huge barriers to change, among them the powerful stakeholders who benefited from this marketized system and resist cost-cutting. this resistance has grown as the u.s. has moved from an industrial to post industrial economy. health care has become a major economic engine in the u.s. about 20% of our gdp. it has attracted venture capital funding because of the reliability of investor returns and the high quality employment opportunities it provides. but that also means it is rife with political landmines. mess with any aspect of it, and you mess with somebody's bottom line and a lobbyist is on your doorstep. meanwhile, our supposedly consumer driven health care in economy is a nightmare for consumers to negotiate. patients trying to shop for a cheaper care are at a tremendous
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due to thee asymmetry i mentioned before. and huge disparities exist in access to care by income level. such inequities seem tolerable in other aspects of his -- a economy, butnted americans have long had a sense that in the words of a 1943 andbook on how to run doctor's office, in the doctors office people are perhaps more nearly equal than anywhere else in the world. we have set up a system, a health care system where that ethos is hard to honor. is faith in marketization one reason. why are the alternatives so hard to envision? i will hand the microphone over to my friend beatrix, who will help you understand that. [applause]
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>> thank you for being here. it is a privilege to be here. the question i am going to look at today is why have we not as a nation been able to reach a political solution to the persistent problems that we have described, the problem of high cost and millions of uninsured people. first, i would like to go back to something nancy said, about her dutch friends in the netherlands never worrying about their health coverage. this idea of relief from worry or from fear about what will happen to us when we need medical care is the reason health insurance was invented in the first place. the reason that over 100 years ago, industrialized countries around the world began to establish a system to protect working people from the high cost of getting sick. it was exactly 100 years ago,
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1919, that such a plan came close to passing in new york. this proposal would have provided workers with medical and hospital coverage as well as partial coverage of the wages they lost when they cannot work. supporters of the plan focused on how it would help alleviate some of the terrible fear that working people felt when they contemplated the vulnerability of sickness. they argued health insurance would rob poverty of one of its worst terrors. the bill was sponsored by a popular republican senator and with his help, it passed in the new york state senate in april 1919 but when it got to assembly, a powerful speaker refused to let it out. his reason was that the health insurance bill embodied to other things americans feared, the
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authoritarianism of germany, who we recently helped to feat in world war i, and that is where social health insurance was invented, and also the newer threat of state socialism emanating from the russian revolution. that was the end of the first campaign for public health insurance in the u.s. as you know, this kind of emphasis on the dangers of socialism and the un-american nature of other countries health systems continued to be heard in battles over health reform for the next hundred years. but there is another way each defeat of universal proposals would make it even harder to succeed the next time around, and that is the way they ended up changing the health care system itself. the first fight over public, nonprofit health insurance led to the idea and growth of private for-profit health insurance. the biggest opponent of the
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legislation in 1919 were employers who did not want to pay a share of the cost and doctors who were worried they would lose their independence, and also insurance companies. commercial insurers had never offered health coverage before. it was seen as too risky. they fought the new york proposal because it included life insurance benefits that would have been in direct competition with their business. in working to defeat the legislation, the insurance industry became aware of a new potential market for their product. here is what one insurance executive said in 1917. "health insurance is engaging interest of all legislators and we should be in a position to meet their socialistic ideas by offering a good brand of sickness protection that we know can be profitably written in a much larger volume." the vice president of prudential agreed
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that arguments in favor of compulsory health insurance be met by such innovation. we will see this pattern again in all the other campaigns for reform. private industry creates mechanisms that will partially meet the need for security but they are designed to prevent universal programs from being passed. these private market-driven developments were also political. private health insurance did not take off until the 1930's but it's birthplace was in the fight over state-level legislation in the 1910's. in the 1920's and 1930's, the focus of health reform began to shift from lost wages to the need for medical care itself. during the depression, reformers pushed franklin roosevelt to ofe health insurance part his social security act. he decided against it, worried that doctors opposition would derail other new deal priorities. but fdr's ideas began to change
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during world war ii. by 1944, he was proposing a second bill of rights which included medical care as a right. after fdr's death, harry truman continued with the idea and push congress to pass national health insurance, which would have fulfilled fdr's promise by expanding social security to include health coverage. national health insurance was part of truman's larger health agenda that included federal hospital construction and expanded support for medical research. unlike earlier proposals, truman's was universal and would have covered everyone. polls show that initially, the majority of the public supported the idea of health insurance for all via social security system. but this was also the start of -- hello, there is nobody there.
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this was also the start of the cold war. when hearings began, senate the mostalled his plan socialistic measure this congress has ever had before it. this kind of attack was familiar from three decades earlier, but something new was that the american medical association ran a multimillion dollar campaign telling the public to fear socialized medicine. this was the first pr campaign of its kind. it may have been the most successful, because after three years, public support went down to 20% and truman plan for -- truman's plan for national insurance never made it to a vote. again, the reaction to this battle changed the health care system. congress agreed to just one part federalarger program, funding for hospital construction.
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this is the hill burton act of 1946, which opponents of national insurance supported because it provided for construction only, with no other type of federal involvement. in fact, hill burton maintained local control so much, he -- it preserved the right of communities in the south to use federal taxpayer funds to build segregated hospitals. so southern democrats supported the legislation, even if they opposed the national health insurance plan. over the next 25 years, burton -- hill burton funded a third of all the hospitals built in the u.s., and brought modern medical care within the reach of millions of people, but the choice to centralized medical care in a hospital while not passing universal health care coverage or building primary care making health care more expensive. it also created the hospital lobby, and the hospital industry
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became a powerful political force in health care debates. the growth of hospital care in the absence of universal coverage also led to the growth of private insurance to pay for all that care. in the 1940's, insurance became tied to employment as firms offered health benefits instead of hard wages during world war ii. in 1943, the irs encouraged this by making benefits tax exempt and congress made that permanent 10 years later. just as hill burton subsidized private hospitals, federal tax policy gave government support to private insurance by certain employers. the job-based system grew until three quarters of the population had coverage by 1960. just as the insurance industry had hoped, private insurance served a political function by presenting what seemed like a private sector solution to the problem of health and security.
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private insurance received via the workplace has major problems. obviously, it didn't cover people without jobs. it also failed to reach millions of americans in low-wage employment, the very poor, and retirees. it became clear that private insurance was not covering enough of the population to provide real freedom from fear of sickness. in backing medicare, jfk and lyndon johnson avoided the opposition of insurance companies because medicare would cover only those people that private insurance could or would not, the elderly. in one of his speeches, lbj returned to the theme of freedom from fear. with medicare, he said older citizens will no longer have to fear that illness would wipe out their savings and destroy lifelong hope of dignity and independence.
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medicare did take a page from truman's book because it was built on social security administrative structure, a program that was familiar and popular. it also made it harder to attack. the ama did try once more. famously, they hired ronald reagan to record a speech in which he insisted medicare would lead to full-blown socialism and the end of freedom in america. this time around, the ama lost. but as nancy told us, the fear of socialized medicine and power of the medical profession, hospitals, and the insurance industry shaped how the medicare program was designed. providers could charge whatever they wanted. the fear of provider backlash led to the absence of budgeting and cost control in medicare. growing cost of
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health care in general, unrestrained medicare payments to doctors and hospitals drove a huge rise in national health expenditures after 1965. but medicare did succeed in at least partly addressing the fear that sickness can devastate us financially and physically. seniors gained a kind of health security no one else in the population had. many thought that medicare would be the first step toward similar security for all americans. instead, by essentially giving providers a blank check, and a -- medicare would make it more difficult to pass comprehensive reform in the future. because after 1970, the goal to expand the number of people covered was overwhelmed by the imperative to control cost. as medical inflation in the 1970's grew, employer health benefits begin to contract. this is when we see the huge numbers of uninsured americans becoming the main drivers for
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calls for health care reforms. by the mid-1980's, nearly 80% of 18% of the nonelderly population had no health insurance at all. there was a crisis in uninsured patients being turned away from ers, transferred in fatal or unstable condition. a situation that got so terrible, congress did act to pass the emergency medical treatment and active labor act in 1986 that at least guaranteed a right to access in the health care system in the emergency room. studies began to show what many people already knew. being uninsured could lead to not just bankruptcy but also debility, suffering, and death. in 1993 and 1994, clinton tried to address the crisis with a plan for universal coverage but this time through regulated insurance networks. that also failed to reach the
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vote. like earlier defeats, this led to a major structural change in the health care system and this was the spread of managed care as an attempt to contain costs. in the 1990's and 2000's, many insured americans had to accept a new kind of health plan that severely narrowed their choice of doctors and hospitals and imposed expensive cost-sharing and sometimes denied them care. pretty soon it seemed like everyone had a high -- a health care horror story from insurance companies refusing to pay for care for pre-existing conditions. people choosing between paying for food and medication, and families driven into bankruptcy after reaching coverage limits. the focus of reform efforts changed to encompass not just the problem of the uninsured, but sometimes the devastating experience of people with insurance. this explains why the drafters of the affordable care act focused partly on expanding coverage but especially on provisions like guaranteed issue, ending provisions for
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-- exclusions for pre-existing conditions and reforming long-standing practices of private health insurance. at the same time, the aca subsidized the same private plans, guaranteeing private thes would continue to be centerpiece of the american health care system. the evidence so far, as well as historical experience, tells us that affordability in private insurance is an elusive goal. instead, the aca and employer coverage, we are seeing more plans with extremely narrow networks of providers and more cost-sharing for patients, features that reduce both choice and affordability. since 2010, 20 million more people do have insurance that didn't have it before. that is a historic achievement. but the insurance does not give them freedom from fear.
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27 million in this country are still uninsured. recently, the ceo of gofundme announced one third of the $5 billion raised on the site each year is for medical expenses. a lot has changed in 100 years. but i guess something has not. during my research i learned about a practice that factory workers had in the early 20th century. the common custom of passing the hat around the shop for the benefit of a sick worker. one woman said that a collection was taken practically every week in the workplace. it would aid fellow employees facing the high cost of sickness. 100 years after we began arguing about health reform, the health care system still does not protect americans from fear of poverty or bankruptcy due to getting sick. i hope that looking back at the original purpose could be useful
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in guiding policy decisions today. thank you. [applause] >> i would like to thank both of our speakers. if you would, please pass the cards with your questions through the aisle and we will pick them up. ok. let's start with this one. since the u.s. health care system has been based on workplace insurance, what implications does this have for women, especially before they entered the workforce in large numbers? >> excellent question.
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women were more likely to not have health insurance for that very reason. not being in the workforce in equal numbers to men. there were also ways that women were discriminated against in employer health insurance. it was uncommon for any plan before the late 1970's to cover maternity care and childbirth because insurance companies thought people should not buy insurance if they thought they were going to use it. since pregnancy was often a planned condition, that was not an insurable condition so women were uninsured and underinsured in great numbers. >> next question. ms. tomes, you mentioned the u.s. leads the world in medical research and cutting-edge innovation. our countries like the netherlands able to make comparable advancements without market-based incentives to do so? >> yes.
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aboutk one of the myths the american way is that this is the only way to get innovation, but in fact, there is not good evidence that this is the only way to get people to innovate and come up with new approaches. there are ways that the american thatm produces innovations european countries are interested in in terms of how we manage medicine, because our system is so complex. some of our management methods are of interest to them. but i think the idea that the only way you can get progress is through our specific model, is simply not borne out in terms of the history of scientific,
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medical innovation. >> i would add to that, the innovations the u.s. is famous for, they were public-private partnerships. the funding that the federal government started to give to our research institutions like the nih and national cancer institute, that is a basic to thee that leads private sector. it is a public-private partnership. >> much of current concern about u.s. health care focuses on high drug costs. is this a new phenomenon, or does it have deeper historical roots? >> not a new phenomenon. it is an interesting area in terms of looking at how government involvement in the regulation of prescription drugs drive acular helped to system of drug development dependent on the use of patent
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protection. encourage innovation and the idea was, the system developed again in world war ii, the encourage innovation and the early 1950's, but it rey set up a system that incentivized innovation, but protected it in a way that made for very high costs in terms of the prescription drugs. so the cost of prescription drugs was already an issue by the late 1950's. people were finding this rise in prices very hard to bear. coverre didn't prescription drug costs until very recently, so this has been an issue for quite some time. people talk about federal involvement in health care, they usually think of medicare and medicaid. veterans affairs also offers government-funded health care. how did it arise and what
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lessons can it offer us? >> excellent question. in some ways, we have had socialized medicine for veterans since at least world war ii. gone up and down in terms of its ability to provide well for our servicemen and their families. in some ways, it became a poster child for fears of what the heavy hand of government bureaucracy would retard innovation, but its problems were simply, if you don't have a system enough money, it is not going to perform well. there are lots of lessons to learn their and historians of the be a system, i can recommend their work, it is fascinating stuff.
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i do review know how the ama has responded to calls for a national health care system today?ou can -- >> this is interesting. the ama was very unified in opposition to universal programs up through medicare and that was their last ditch attempt to oppose a national reform. after the 1970's, costs started increasing and private insurance increased its role in the system, doctors' views started to change. not necessarily reflected in the ama which doesn't represent all doctors, but by the time of the clinton debates in the 1990's, physicians were much more divided than they had ever been. one of the main reasons for that fought national healthcare because they wanted to preserve their independence and ability to practice medicine as they saw fit.
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by the 1990's, many, many physicians were now practicing under the thumb of insurance companies. they were not independent anymore. they began to see more value in a system in which everyone would be a short -- insured and it would remove the barrier between doctor and patient that the insurance companies had become. likeprovider groups, family and emergency medicine, come out moreve strongly since the 1990's in favor of universal plans. the ama today is back to its old it comes to advertising. i saw some of the new ads that are being put out against the medicare for all idea. isseems to me that the ama coming out against the proposals for single payer but that
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shouldn't lead us to make assumptions about what ' position is because positions are more diverse than they used to be and their organizations are. >> i want to underline the no onety as, there is physician position on anything. there wasn't in fact in the past, as well. there were always doctors who were critical of the fee-for-service system i described, and that predicted the problems that would arise with it. i would say today, one of the major divides in physician opinion is around the primary care physicians who, their position has eroded dramatically since world war ii, so people who provide general, basic kinds of care are really at a disadvantage in the current marketplace, and they are much more interested in solutions
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that might shift that. i talked about the generalists and specialists, shifting generalists back to specialists. that is a big difference between european systems, where the control of her specialism is much tighter. you can't just go to a and --ist anytime anytime you decide to. >> you mentioned unions. do you think the decline of unions is connected to the health crisis? >> yes. [laughter] historythere is a long that we can't get into in terms of how the organized labor movement helped in many ways to gain health insurance through the collective bargaining process. in a way, because of weaknesses in that organized labor movement, it left out women, people of color, it kind of shot itself in the foot but i think
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it has revived. i talked about postindustrial economies organized around service industries, so service industry unions have come back and are players in terms of trying to change the insurance. but akin the day -- back in the day, when organized labor was seen as not equivalent, but having power like, we -- like organized business or medicine, they had more clout than they did by the 1970's. >> they could drive a better rate from blue cross blue shield. >> and make it more comprehensive. >> and the membership. >> that is backed in a way that a became -- they became tarred with the brush of, they are for communistic, socialistic medicine. reforms in european countries
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were kind of tarred with the brush of, you are taking us down the road to the evil empire of dominance. the examples of european countries are fully applicable to the united states, despite having much smaller populations? >> yes and no. point taken that the netherlands is the size of maryland, so the problems they face are different. if you look at germany, that is a bigger country with a larger population. i do think the united states could learn a lot by looking at democraticitalist peer nations managed the rise of biomedicine since world war ii. that notrect everything is going to be applicable, but i think trying theet a sense of why
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cultural preconceptions are so different, in my work i have come to see world war ii as the kind of fulcrum, because countries like germany and the netherlands and france were a sense ofthey had rebuilding, of solidarity that you simply don't see in the united states. we fought in world war ii, but we didn't suffer the same devastation in our own land, and we didn't come out of it with the same sense of having to rebuild from the bottom up. i think there is a lot we can learn. to your question, it will be selective because in a lot of ways, our examples are not comparable. systems that nancy is talking about in europe are also very diverse. we can look at different models, but there is one thing they all have in common.
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anywherehat can apply regardless of population. some are single-payer, some are multi-payer, some have private insurance, some are socialized medicine but they all have in common that everyone is covered. every resident in the country is covered, and that leads to a pooling of risk, which brings down cost. the other thing they have in almost everyt provider is in the system. all the patients are in the same system and all the providers are in the same system, which leads to choice of provider. those are lessons that can be applied to a country of any population. >> are legacy of world war ii was the fact that many wounded veterans had excellent medicare -- medical care, and they wanted that for themselves and their families matter what it would take to do that. it was the first experience withcans had en masse
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excellent health care. >> it was a source of support for the truman-type plan. it just didn't go, it didn't succeed. >> there was a socialized system during world war ii briefly, for maternity care for soldiers' wives, maternity infancy care act. it was temporary. dear to mynear and heart. how do you think historical scholarship can be a useful tool to inform and give decisions, to inform and help with the decision-making by policymakers? >> i think we have to look at history in order to have an honest conversation about what is happening now. a lot of the rhetoric that we hear around health reform debates today is not really based on accurate descriptions of the u.s. health-care care system or foreign health care
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systems. so we have to understand, what are the definitions? what do we mean? when we say universal health care, single-payer, things like that? how do foreign countries do what they do? i think history, if i can brag about a profession, does a good job of providing accuracy in debates. so let's hope for that. >> history always helps. if the key is reforming private insurance, how can we go about doing that? well. >> we saved the toughest for last. >> the question of how you change a system when you have such a powerful economic investment, and how many people worked in the private insurance industry? if we went tomorrow to medicare for all as a single-payer
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government run system, how many people would be out of a job? one of the arguments for the system that i described was the high paying employment that it produced, and all the people who delivered the health care. as you probably know, our administrative costs for how we deliver health care are the highest in the universe, probably. we invest a huge part of our thath care dollar in management and we see it as ideologically superior because like private, but we also the economic benefit. changing that is really going to enormous, i would say, brokering of economic interests of the private insurance industry could, could except the change. that is one reason i personally
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a more step-wise plan is more likely to work because they are not going to go away like that. we really want health care to be more affordable, it is difficult to see a role for private insurance as it now exists. the system, besides ours that include a role for private areanies, most of them actually nonprofit. they are private but nonprofit. to take out the profit motive is obviously going to be a major way of reducing costs. it will reduce administrative costs and overhead. i think i am more leaning towards thinking private insurance, it's going to be hard to find a solution for that entity, especially because they currently have two much say in be aolitics and they may stakeholder, but the mainstay colder in the health care system
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is the people of this country -- the main stakeholder in this health care system is the people of this country. private insurance should have less of a say in how we develop our system. >> one characteristic of our european peers is, they tolerate a higher level of government regulation. provide a writer -- provider behavior, and who gets what care. we can accept the principle the government needs to regulate, and i mean hard regulation, these problems are impossible. we are clearly not to that place. >> change of consciousness. time for one or two more. how have states relationships with the health care system evolved over time? a question about state initiatives. >> great question. >> the health insurance debates began at the state level in the
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progressive era. it was almost entirely state proposed because national insurance was, was seen as something that shouldn't happen at the federal level. the role of the states was of course preserved in medicaid. i know there is a lot of hope for state experimentation that could help improve the health care system, but i think the reality, historically, is that ton health care has devolved a state responsibility, that embeds a lot of inequity in the system because there is so much inferential between states terms of medicare benefits, in terms of who they cover. so the states certainly have a role to play. but they have also had a big role to play in preserving inequities in our system. >> on a more optimistic note, i think because of our federal
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layer cake system, there is potential for states to try out different funding schemes, and possibly show that a move towards let's say a more european-style model might be possible. if you can make it work in massachusetts and washington state, that could possibly influence federal policy. that is an optimistic view. >> last question. what common themes have you observed drug history of health care regarding both what seems to be problematic and what creates progress? great question. >> go for it. >> the problem is easy. that is mostly what we talked about. the theme that keeps coming up -- in thetortion and
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debates. the debates that take place , theycally are not distort the reality of our health care system. so we haven't had an honest discussion of how we actually deliver health care in this that is what is necessary in order to change it. >> i would say one of the lessons i have learned is the dangers of hyper-individualism and the importance in health care of having a sense that this, quoting a recent commentator, that america has lost its sense that we are all wethis together, and that don't have a sense of solidarity. this is what my dutch friends are like, what is wrong with you people? it's that hyper-individualism. we think it is so important to individualize everything and to have competition. the worst thing you could do for the american character would
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leave people to the fear that your health care isn't covered. that people would be lazy and unmotivated. that is the ideology that drives this, the fear of a welfare mentality taking over. this is not going to be your family, it is the family across the street and across the city, whose skin is a different color or didn't grow up in the united states. individualism versus solidarity. aren't we all in this together? big question. it bears discussion. >> along those lines, one example of success, something that has worked, is not a top-down process. medicare is often attributed to the power of lyndon johnson and his negotiating prowess. he was amazing. by he was actually pushed the civil rights movement and senior citizen organizations to
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take the stand he did on medicare. i think it goes back to the they areganizing and the ones who push the politicians to make change in the face of all the obstacles. >> tough questions, excellent answers. thank you all for coming this morning. [applause] please join me in thanking our panelists. [captions copyright national cable satellite corp. 2019] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit] monday, aty weekend, 8:00 p.m. eastern, the commemoration of the 400th anniversary of virginia's first general assembly held in jamestown. explore our nations cast on american history tv every weekend on c-span3.
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>> in 1979, small network was an unusual name with a big idea. less -- let viewers make up their own minds. -- c-span brings you unfiltered content from congress and beyond. today, c-span is more relevant than ever. your unfiltered view of government so you can make up asr own mind, brought to you a public service by your cable or satellite provider. >> jean becker was chief of staff to judge h.w. shortly after he left the white house and up until his death in 2018. this weekend, on the presidency, ms. becker talks about the man she knew. here is a preview. this is a prince of saudi arabia, the saudi ambassador to the united states from us 20
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years, the ambassador during president bush's residency, president clinton, lots of george w. president bush was very close to him. callush brothers used to president clinton their brother by another mother and they gave the prints the same nickname. -- the prince the same nickname. seven or eight years ago i got a call late at night from somebody who used to be in president bush 's administration to ask me if i had heard anything about the the head of what was essentially the cia in saudi arabia. she said, we hear that he has been be fascinated. have you heard this? so i break the news to him and he said, have you tried calling him? i said, no. [laughter] that really hadn't occurred to
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me. to call him. he says, let's try to get him on the phone. so we are sitting outside in upstairsnd i holler with the office windows open, and one of his assistants, jim appleby, leans out and i said, can you get the prince on the phone for president bush? he said, have you called him? i said, yes i have. two minutes later he leans back out. this will be a chapter title, the prince is online two. president bush picked up the phone. bush.ent bush says, it's are you dead or alive?
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learn more about george h w bush from his chief of staff. nation's passed on american history tv. an annualage days is event held in may at the u.s. army heritage and education center in pennsylvania. hundreds of living history hobbyists conduct demonstrations and talk to the public about the military, from the american revolution to the war on terror. the theme this year was the d-day 75th anniversary. next come on american artifacts, living-- we visit a american history camp to learn about the experiences of the army's parachute regimental combat team. u.s. soldiers who fought in the maritime alps of france in 1944. >> good morning. my name is matt holmgren.


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