In Health Care for Some, Beatrix Hoffman offers an engaging and in-depth look at America’s long tradition of unequal access to health care. She argues that two main features have characterized the US health system: a refusal to adopt a right to care and a particularly American approach to the rationing of care. Health Care for Some shows that the haphazard way the US system allocates medical servicesusing income, race, region, insurance coverage, and many other factorsis a disorganized, illogical, and powerful form of rationing. And unlike rationing in most countries, which is intended to keep costs down, rationing in the United States has actually led to increased costs, resulting in the most expensive health care system in the world.
While most histories of US health care emphasize failed policy reforms, Health Care for Some looks at the system from the ground up in order to examine how rationing is experienced by ordinary Americans and how experiences of rationing have led to claims for a right to health care. By taking this approach, Hoffman puts a much-needed human face on a topic that is too often dominated by talking heads.
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About the Author
Beatrix Hoffman is professor in the Department of History at Northern Illinois University. She is the author of The Wages of Sickness: The Politics of Health Insurance in Progressive America.
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HEALTH CARE FOR SOMERights and Rationing in the United States since 1930
By BEATRIX HOFFMAN
THE UNIVERSITY OF CHICAGO PRESSCopyright © 2012 The University of Chicago
All right reserved.
Chapter OneA Crisis of Access
On a wintry Chicago morning in 1936, ten-year-old Vera Lahr began complaining of stomach pains. Suddenly, she doubled over and started vomiting "green stuff." Her panicked mother immediately called the charity clinic where she had been taking the children since their father lost his job. Now that the family was "on relief," they could no longer afford their former family doctor, but the clinic told Mrs. Lahr to call him anyway since there was nothing they could do for the sick girl. Mrs. Lahr phoned the doctor several times and even sent one of her other children down to his office. Hours passed, but "still he did not come." Later that afternoon, the doctor sent word that he would be over "after office hours." When he finally arrived, he immediately ordered the girl hospitalized. Shortly after surgery disclosed her burst appendix, Vera Lahr died.
The Lahrs claimed that Vera lost her life because she was a clinic patient and her family was on relief. Her grieving father told an interviewer that he "blamed the doctor's indifference, and the lack of immediate medical care as the cause of his daughter's death." Although they had known the doctor for years and even considered him a friend of the family, the Lahrs felt that he was annoyed with them "because they had not been doctoring with him in recent years ... they had been going to clinics where services were free." The family believed that by accepting charity medical care they had lost their standing with their former physician—a loss that, in her parents' eyes at least, cost Vera her life.
Despite its unusual drama, Vera Lahr's story encapsulates many of the changes that ordinary Americans experienced when seeking medical care during the Great Depression. Like Vera's father, millions of breadwinners found themselves suddenly out of work and turning to relief in the form of government cash or work assistance. Relief checks were inadequate to cover a family's most basic expenses, much less medical costs, and local relief authorities' responsibilities did not include financing health care. Large numbers of families attended "free" or charity clinics or used public hospitals for the first time during the Depression. Public and charity facilities that had been designated for the poorest of the poor now overflowed with the newly impoverished—people who had previously been able to afford private doctors but could no longer do so. As the formerly employed and their families found themselves suddenly flung into medical indigence, the public-private health system struggled to accommodate the new demand.
With no coordinated system to care for them, the newly indigent had to navigate a complicated patchwork of rationed services: government and voluntary hospitals, charitable physicians, private and public clinics and dispensaries. Each service had different requirements for access or eligibility; a patient rejected for one type of care might be eligible for another, but the standards proved variable and sometimes mysterious. Facilities could be difficult to get to and far from each other, making transportation a crucial part of access—in Vera Lahr's case, a matter of life or death. If the Lahrs had been able to call an ambulance Vera might have made it to a hospital sooner, but Chicago in the 1930s had no public ambulances, and the city's 22 private ambulances were too expensive for people on relief. No US city had a coordinated plan for emergency health services during the Depression, and the clinics on which the poor depended were not equipped to deal with emergency cases.
Access to private physicians depended on ability to pay or the doctor's willingness to provide care at reduced rates or free of charge. As the Lahr case illustrated, the Depression brought physicians' ambivalence about charity care to a head. Some physicians supported the expansion of charity and government clinics and hospitals to relieve the medical profession of the growing burden of free care, but others deeply resented free or low-cost facilities for luring away patients who had previously been willing or able to pay doctors' fees.
The health care system of the 1930s not only failed to guarantee access; it also offered no rights of recourse for people who were denied medical care. After the Lahrs lost Vera, they complained only to a social work student who interviewed them for her thesis on health care in their West Side neighborhood. There was no official way for patients to make themselves heard about neglect or poor treatment from doctors or hospitals. Even if the family had wanted to take their doctor to court, malpractice law offered no course of action for patients who had been denied medical care, since malpractice could occur only after treatment by the physician had begun.
The sudden increase in the need for affordable health care during the Great Depression directly challenged the ideology and institutions of voluntarism. Physician charity, private philanthropy, and voluntary hospitals and clinics, despite their best efforts, proved incapable of meeting the demand. As the economic crisis deepened, many leaders of voluntary institutions argued that the new conditions required an increase in government's responsibility to subsidize care of the indigent sick.
The role of government itself was undergoing massive change during the Great Depression. Workers, the unemployed, and the elderly joined together in vocal organizations demanding an increased federal role in the economy and in the protection of ordinary people's security. The programs of Franklin D. Roosevelt's New Deal embodied many of these new ideas about government responsibility. This was a time of talk about economic rights and security. It is no coincidence that the first explicit discussions of a right to health care in the United States began during the Great Depression.
One part of the story is well known ( and will be discussed further in chapter 2): the President gave in to pressure from the medical profession and refused to include health coverage in the Social Security Act. Even so, the Great Depression transformed government's relationship to health care. By the end of the 1930s, the crisis of access had forced local, state, and even the federal government to play a greater role in health provision than ever before. New voluntary institutions, including private health insurance, emerged to challenge the state's encroachment into the health field, but the trajectory of government involvement begun in the 1930s would only gain momentum during the decades that followed. As this section of the book will show, however, new responsibilities for government did not at first translate into new health care rights for citizens.
Even before the economic depression threw millions into unemployment after 1929, the United States experienced a great disparity between impressive medical progress on the one hand, and unequal distribution of health and medical resources on the other. In the first three decades of the twentieth century, life expectancy for the average American increased from 47.3 years to 59.7, thanks to improved sanitation, vaccination for some contagious diseases, and new treatments for diseases like syphilis. Yet, notes historian John Duffy, "the advances in medicine and public health did not benefit all Americans."
Even at the height of prosperity in the 1920s, "millions of families cannot afford to obtain any medical care," reported the Committee on the Costs of Medical Care. "Hundreds of thousands of cases of sickness needing medical attention are unattended; less than seven percent of the population have even a partial physical examination and less than five percent are immunized against some disease." Although scientists and doctors were making great strides against scourges like tuberculosis, diphtheria, and venereal diseases, health reformers argued that these disorders remained far more common than they should have been because of the nation's uncoordinated and inadequate medical services.
When the Depression struck in 1929, the age-old correlation between poverty and sickness became even more evident. Urban areas experienced increasing rates of illness during the early 1930s. A study of several large cities by the US Public Health Service in 1933 found that lower-income population groups experienced higher incidences of disabling illnesses, with the greatest increase among families who had a drop in income due to recent unemployment. Workers who lost their jobs and had to go on relief had higher levels of chronic disability and their children lost more time from school because of sickness than people with higher incomes. "Unemployment means a greatly reduced standard of life," asserted an organization of the unemployed. "Long hours, low wages and bad working conditions when there is work, undermine health. Relief and poverty diets lower resistance."
Rural areas continued to suffer high rates of "preventable or treatable diseases such as pellagra, hookworm, syphilis, tuberculosis, malaria, and typhoid ... stark reminders," points out historian Michael Grey, "that rural America had been materially poorer than the rest of the nation for decades." Nearly half of all loan defaults among farmers were linked to sickness in the family. The devastation of the rural economy by drought and depression meant that by the early 1930s, doctors in the countryside were able to collect less than half of their bills.
In both urban and rural areas, race played a part in sickness and health. While overall life expectancy was improving, African Americans' life spans fell increasingly behind those of whites. Black infant mortality in South Carolina, to give just one shocking example, was over 15 percent in the 1920s, meaning that 15 percent of black newborns would not survive their first year. In Chicago, the tuberculosis rate among blacks was five times as high as among whites. Higher disease and mortality rates were always attributable to poverty and overcrowding, but also to overt racial discrimination. South Carolina had far fewer hospital beds for black tuberculosis patients than for whites, even though blacks suffered from the disease in far greater numbers. Blacks in Chicago were routinely sent to overcrowded Cook County Hospital instead of the closest hospital because of their race.
Medical progress itself created a new challenge: the rising cost of health care. More Americans entered hospitals for serious illnesses, and in the 1930s childbirth began to shift from the home to the hospital. More doctors trained as specialists, raising the price of physician services. Technological advances, particularly improvements in anesthesia, also increased the cost of care. National medical expenditures in 1929 exceeded $3.5 billion ( around $30 per capita)—less, noted the CCMC report, than annual expenditures on tobacco or automobiles, but increasing each year.
The economic depression, coupled with rising physician and hospital costs, pushed medical care beyond the reach of many Americans. Sudden illness, chronic disease, childbirth—each could take a devastating toll on family finances. In a survey of medical costs in one Chicago neighborhood, a woman called it "disgraceful" that her daughter and son-in-law had just finished paying the doctor and hospital bills for their baby's birth—and "the child was past two years old!" For a diabetic, "all of her earnings ($50.40 a month) went for medicine, appliances and a special diet." An Italian immigrant had given up a visit to the "old country" in order to pay the doctors' bill of $313 to remove a breast lump. Her family "'hadn't had a doctor in their home for years—they 'couldn't afford to get sick!'" 13 Sometimes, people had to forego care altogether, like a woman who needed cancer surgery that would cost $100, but canceled the operation after her husband was laid off.
Both the poor and the middle class went to private doctors less often during the Depression, and when they did go, they had a harder time paying. One national survey found that 66.6 percent of doctors' bills were delinquent in 1933. Although some doctors refused to see or limited patients who could not pay, many others continued to be "generous with their services and did a great amount of 'charity' work." The result was a dramatic drop in physicians' incomes of 47 percent between 1929 and 1933. "Many physicians, surgeons and dentists," lamented the Chicago Medical Society Bulletin in 1934, hovered "on the verge of privation because they could collect no money for the work they did." The nursing profession also experienced severe distress, with 60 percent of all nurses unemployed by 1932–33.
The economic crisis threatened hospitals, too. Admissions at private hospitals dropped during 1931–33, and the patients they did have were less likely to be able to pay. Charity patients—including those paying part of their costs on a sliding scale—accounted for 40 to 50 percent of all patients admitted to voluntary hospitals nationwide in 1933, an increase of 25 percent in three years. In 1932, the total patient load in New York City's private general hospitals dropped 13 percent, but service in these hospitals to "free" patients nearly doubled as the Depression created an enormous increase in the demand for free medical care. The following year, the city's public hospitals operated "at an average of 110% of their rated capacity," with "beds in the aisles, queues at the clinics." Both government and private hospitals and clinics faced a major shortfall in patient fees, coupled with a decline in philanthropic giving. The many physicians willing to give care found themselves increasingly unable to afford to do so. Yet the health needs of the population continued to increase. Who was to care for the swelling ranks of the indigent sick?
Storming the Clinic Doors: Crisis in Chicago
In the summer of 1938, on the second day of the National Health Conference convened by President Franklin D. Roosevelt in Washington, DC, a woman named Florence Greenberg rose to speak. "Yesterday," she told the audience, "Dr. West of Chicago extended an invitation to the delegates ... to visit the American Medical Association offices in Chicago to see its accomplishments. I, too, want to extend an invitation to the delegates present here to visit Chicago—but I want to show them another picture. I want to show them a sick Chicago, a Chicago of dirt and filth and tenements." Greenberg, a member of the Steel Workers Organizing Committee, spoke of how she had seen families devastated, first by unemployment, and then by sickness and lack of medical care.
The Depression had hit Greenberg's city especially hard. Chicago was heavily dependent on manufacturing, and 50 percent of its factory workers had lost their jobs by 1933. A tax revolt left the city government bankrupt and forced public school teachers to go without pay for months. Chicago's large African American population suffered especially high rates of unemployment—a devastating 40 percent—exacerbated by job segregation and racial discrimination. One historian describes Chicago early in the Depression years: "World War I veterans took to selling apples on Loop streets. Some found their way to the bread line sponsored by Immanuel Baptist Church. Here, 1,500 to 2,000 would line up two blocks long to receive bread, coffee, and on alternate days meat ... Homeless men erected shanties on scattered vacant lots throughout the city ... Hundreds of children came to school without breakfast, existing on one meal per day."
Although not as famous a medical center as Boston or New York, Chicago was still better equipped than most cities (and all rural areas) to handle the needs of the indigent sick. The city boasted the fine medical schools of the University of Chicago, University of Illinois at Chicago, Northwestern, and Rush, and was headquarters to the American Medical Association and the American Hospital Association. Chicago had dozens of private, voluntary hospitals, including Catholic, Protestant, and Jewish hospitals as well as ones catering to the Swedish, German, and African American populations.
The city was also home to Cook County Hospital, one of the largest public general hospitals in the country. Before the Depression, most Chicagoans saw the county hospital as a place only of last resort. "Workers are afraid of going to 'Cook County,'" said Greenberg; "they look upon it as sort of a death house." Some low-income people preferred to incur private hospital bills rather than enter County; one woman went to a Catholic hospital during a hemorrhage, even though she couldn't afford it, because "she was too sick to go through all of the necessary red tape before she could have been admitted to Cook County Hospital." ( Her bills remained unpaid two years later.)
But, the poor and unemployed generally had no choice other than "County," and more and more Chicagoans relied on the hospital during the Depression. Yearly admissions rose from 45,953 in 1930 to 68,014 in 1940.25 At the same time, Chicago's private hospitals lost paying patients in droves; by 1934 half of all "pay beds" lay unoccupied, even as Cook County Hospital became vastly overcrowded. And more than half of the patients who were admitted to Chicago's private hospitals in 1933 were classified "unable to pay."
Even more than on the private hospitals, the weight of the growing numbers of newly indigent sick fell on Chicago's outpatient departments and clinics. Individuals not sick enough for inpatient care and unable to pay a private physician turned to the outpatient departments of the larger voluntary hospitals, or to freestanding clinics sponsored by a hospital or private agency. Clinics treated working people and the poor for both acute and chronic conditions endemic among these groups. The Clinic Section of the Council of Social Agencies (CSA), an umbrella organization of Chicago charities founded in 1914, oversaw Chicago's private clinics, dispensaries, and outpatient departments. Council leaders fiercely upheld the tradition of private charity and voluntarism in Chicago, but the Depression radically challenged their belief that private institutions could meet the medical needs of the population without help from the government.
Excerpted from HEALTH CARE FOR SOME by BEATRIX HOFFMAN Copyright © 2012 by The University of Chicago. Excerpted by permission of THE UNIVERSITY OF CHICAGO PRESS. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents
Rationing and Rights: History and Definitions
Prologue: Rights and Rationing before 1930
Part I: The Struggle for Health Care in the Great Depression
Chapter 1: A Crisis of Access
Chapter 2: Social Security without Health Security
Part II: Prosperity and Exclusion, 1941–64
Chapter 3: Health Care at War
Chapter 4: Rights to Refuse: The Triumph of the Hospital
Chapter 5: Rationing by Coverage: The Rise of Private Health Insurance
Part III: New Entitlements and New Movements, 1965–80
Chapter 6: Entitlements but Not Rights: Medicare and Medicaid
Chapter 7: The Rise of Health Care Activism
Part IV: Rights vs. Markets, 1981–2008
Chapter 8: Emergency Rooms and Epidemics
Chapter 9: At the Breaking Point
Epilogue: Rights, Rationing, and Reform