Health Policies, Health Politics: The British and American Experience, 1911-1965

Health Policies, Health Politics: The British and American Experience, 1911-1965

by Daniel M. Fox
Health Policies, Health Politics: The British and American Experience, 1911-1965

Health Policies, Health Politics: The British and American Experience, 1911-1965

by Daniel M. Fox

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Overview

Drawing on a wide range of sources, from popular literature, movies, and television drama to government and institutional documents, this book reveals similarities in the presumptions underlying British and American health policies, while also exploring the distinctive way in which policy was shaped by political culture, class relationships, and economic resources in each country.

Originally published in 1986.

The Princeton Legacy Library uses the latest print-on-demand technology to again make available previously out-of-print books from the distinguished backlist of Princeton University Press. These editions preserve the original texts of these important books while presenting them in durable paperback and hardcover editions. The goal of the Princeton Legacy Library is to vastly increase access to the rich scholarly heritage found in the thousands of books published by Princeton University Press since its founding in 1905.


Product Details

ISBN-13: 9780691610764
Publisher: Princeton University Press
Publication date: 07/14/2014
Series: Princeton Legacy Library , #661
Pages: 248
Sales rank: 806,429
Product dimensions: 6.10(w) x 9.10(h) x 0.70(d)

Read an Excerpt

Health Policies, Health Politics

The British and American Experience, 1911â"1965


By Daniel M. Fox

PRINCETON UNIVERSITY PRESS

Copyright © 1986 Princeton University Press
All rights reserved.
ISBN: 978-0-691-04733-1



CHAPTER 1

Health Policy and the Perception of Medical Progress: 1910-1918


In the early twentieth century, many people in both Britain and the United States believed that health policy should be reformulated. Enormous changes were occurring in medicine. For the first time, people of all social classes expected to be hospitalized for serious illnesses. New instruments and techniques made diagnosis more precise. Scientific advances and the publicity accorded them in the press had stimulated optimism that new therapies would soon be discovered. In both countries, more stringent requirements for medical education and entry into the profession combined with the increase in hospital practice had stimulated the emergence of new medical elites. The authority of the members of these elites was grounded to an increasing extent in their knowledge and the prowess imputed to them by colleagues, patients, and by the mass media. Social class still mattered in medicine, but not as much as it had earlier, and considerably less in America than in Britain. Although relationships between the new medical elite and general practitioners were often tense, doctors were, in general, united by a sense of professional solidarity and by a shared commitment to the application of science to medicine.

Politics and society in Britain and the United States were, however, profoundly dissimilar. Britain was a more cohesive society, though with considerable diversity: there are important differences, for instance, among England, Scotland and Wales that are beyond the scope of this book. Nevertheless, debates about policy in Britain occurred among people who, despite frequent disagreements, had a great deal in common. Centralization — of policy and politics, of the allocation of prestige, of the media of communication, of the organizations that represented political and professional interests-made disagreements easier to resolve in Britain than in the United States. Habits of deference restrained the antagonism of classes. Moreover, an aristocratic tradition of paternalistic responsibility to alleviate suffering often led to policies that were similar to those derived from socialist theory. The United States, in contrast, was characterized by a more fragmented polity, a fluid class structure, and a narrower range of ideological debate.

Despite these differences, the primary issue for health policy in both nations by 1918 became how to organize and finance medical services. In Britain, every sector of the medical profession and major figures in government, social reform, and voluntary associations were gradually drawn into discussions about organizing and paying for services. In the United States, a coterie of reformers in medicine and philanthropy promoted reorganization while the major associations within the medical profession grew increasingly resistant to it.

Just a decade earlier, organizing and financing medical care was still a subordinate issue in debates about priorities for social policy. Legislators, officials, and leaders of voluntary associations concerned with social problems accorded priority to improving wages and working conditions, preventing or alleviating unemployment, and ameliorating long-term poverty through pensions, education, and improved nutrition.

However, concern about poor health and optimism about medical intervention to remedy it gradually influenced thought and action about social policy after the turn of the century. Social investigators in both nations claimed that illness was a significant cause of poverty. Theorists of human capital and industrialists impressed by new ideas of scientific management argued that healthier workers were more productive. Philanthropists, journalists, and officials were dismayed by the large number of sick children and of adult males disqualified for military service because of poor health. This concern about the health of the working class united imperialists and pacifists, advocates of social insurance and of charity, eugenicists and environmentalists, as well as free enterprisers and socialists. In the United States, the euphemism for improving the health and productivity of the lower classes was "national vitality"; in Britain, it was "efficiency."

In the second decade of the century, compulsory or government health insurance became a public issue in both nations. Within a few years, however, the nature of the problem prominent people in each country wanted to solve with health insurance underwent a profound change. When compulsory health insurance was first proposed, its advocates linked it with social policy to alleviate and prevent poverty. In each nation, however, policy for medical care was gradually separated from general social policy.

By the end of the First World War, the purpose of compulsory health insurance was subtly but decisively redefined. A policy to avoid destitution was transformed into a policy to expand access to desirable services in order to alleviate disease. The organization, financing, and substance of medical services became the central concern of officials and social reformers who were concerned with policy for health.

This redefinition of the problem to be addressed by compulsory health insurance created a major discontinuity in the history of social policy. Social insurance had been instituted in Germany in the late nineteenth century to provide alternatives to socialism. The purpose of social insurance was to reduce the antagonism of the working class toward employers and public officials. In Britain and the United States, similarly, philanthropists and political leaders initially advocated social insurance in order to increase the working class's share of the nation's wealth on terms set by the dominant classes in society. The alleviation of disease, however desirable, was not a central purpose of social policy.

Moreover, the earliest advocates of compulsory health insurance in Britain and the United States described it as an installment on a larger program of social reform. David Lloyd George, chancellor of the exchequer from 1901 to 1914, believed that "at no distant date, [the] state will acknowledge a full responsibility in the matter of provision for sickness, breakdown or unemployment." The American Association for Labor Legislation, which, between 1915 and 1920, promoted a model bill for compulsory health insurance, advocated a program of reform that included improvements in wages, working, and housing conditions and the regulation of collective bargaining.


National Health Insurance in Britain

The priority of health policy in Britain changed within a few years from maintaining income to providing services. When, in 1911, Lloyd George introduced national health insurance, his priority was protecting the wages of workers who could not work because they were sick. This policy antagonized influential groups to both his left and his right who worried that workers would be corrupted. To his left, Fabian socialists led by Sidney and Beatrice Webb argued that sick benefits should be paid only to workers who demonstrated willingness to adopt what they called better habits of life. To his right, defenders of a distinction between the deserving and undeserving poor, which had been drawn since Elizabethan times by a succession of laws to regulate the burden of the poor on society and which had been reinforced by conservative Social Darwinism argued, as the author of an unsigned article in the Times of London wrote, that "if you offer people ... relief without any drawback, it is absolutely certain that many will take advantage of it."

Lloyd George modified his program in order to accommodate his opponents' views. Introducing the insurance bill to Parliament in 1911, he conceded that a sick allowance should be paid only to patients who demonstrated deservingness by obeying doctors' orders. Benefits should be conditional on good character rather than an entitlement in all cases of illness. Lloyd George also intended to expand the scope of health insurance. To organize the program he appointed a junior minister, Charles Masterman, who had written a best-selling book celebrating what he called the progress of the modern campaign against disease. Lloyd George and Masterman planned to mount what they called a "succession of attacks" on specific diseases, beginning with tuberculosis, through health insurance. They chose as administrator of national health insurance a forceful civil servant, Robert Morant, who wanted medical services, not cash, to be the focus of the program. Moreover, Morant wanted the priority of health insurance to be "organizing medical treatment for all wage earners." He hoped that workers would be "enthusiastic consumers" of medical care, even though they "resented compulsory deductions from their wages."

Morant, who was close to the Webbs, was influenced by changing Fabian opinions about health policy. In 1906, Beatrice Webb disparaged what she described as the mere dispensation of physic. By 1910, however, she advocated public and philanthropic policy to extend curative services. Hospitals would increase in number, she assured the British Hospital Association at its first meeting. In 1912, she decided that medical care was part of what she called a war against poverty. The advance of sanitary science, medical and surgical discoveries, and improvements in personal hygiene were, she claimed, the greatest triumph of the nineteenth century. In 1916, she looked forward to a public medical service managing one disease after another. Similarly, by 1918, Sidney Webb, calling for a threefold increase in hospital beds, asserted that "so long as hospitals are not adequate ... for all cases requiring them, we cannot get the health of the people improved or premature death postponed."

Leaders of the medical profession also wanted to change the purpose of health insurance from providing cash to purchasing services — from remedying poverty to diagnosing and curing disease. Medical opposition to NHI disappeared quickly as, under it, doctors' incomes rose and their professional autonomy increased because they were freed from what they regarded as the petty restrictions of voluntary group insurance administered by Friendly Societies. Christopher Addison, a doctor who was a member of Parliament and an ally of Lloyd George's, declared in 1914 that he saw no limit to what he called "enlightened cooperation between medicine and the state." With support from the medical profession, Lloyd George and Masterman intended in 1914 to extend insurance to cover specialists' services, but postponed legislation because of the war.

Events during the war accelerated changes in the priorities of health policy. At home, the central government improved and extended the medical services provided by local authorities in order to maintain the productivity of civilian workers despite the absence of half the doctors in military service. More important, the achievements of medicine at the front were widely celebrated. Death rates from contagious diseases and from infections related to wounds were considerably lower than in previous wars, as a result, many experts concluded, of both scientific knowledge and the way services were organized. Emergency surgery in field hospitals had never been so successful. Moreover, military experience increased the number of doctors who had experience of the coordination required to use new machinery for diagnosis and anesthesia. The way services were organized on the battlefield added new words to the vocabulary of civilian medical care: receiving stations, base hospitals, and sectors, for example. As the Times' medical correspondent said, the war taught both the public and doctors the "value of teamwork" and the "need of applied science in medical treatment."

By the end of the war, there was a broad consensus about health policy in Britain. But consensus had been achieved by ignoring the problem of how to measure the extent to which medical care alone was an effective remedy for poverty. The most penetrating analysis of the new health policy was written by William Brend, a barrister who lectured on forensic medicine at Charing Cross Hospital.

Brend was uncertain about whether medical services were an effective remedy for poverty. In 1914 he had asserted that medicine was fighting a winning battle, but warned that it was a mistake to suppose that medical treatment was mainly responsible for preventing sickness or reducing the death rate, Three years later, evaluating National Health Insurance, Brend was still ambivalent about the significance of the progress of applied medical science. On the one hand, surgery had, he said, played a larger part than sewers in the decline of the death rate since the nineteenth century. Moreover, the logic of progress made it inevitable that general practitioners would gradually be replaced by hospital-based specialists. On the other hand, compulsory insurance had failed to improve the health of the working class. Moreover, some of the healthiest people in Britain lived where doctors and hospitals were fewest. Brend could not explain how this mismatch of health status and the location of medical services could exist if access to care were the principal cause of the reduction of sickness and death.

Brend's uncertainties led him to advocate social policy to create more medical services and to raise income and living standards. NHI should be expanded to cover hospital service. The preventive and curative medical services of local authorities should be unified, he wrote. At the same time, he added, the nation needed a broad program of social insurance and housing reform, what the Webbs called the National Minimum.

Most of Brend's contemporaries had no difficulty agreeing with him. They did not find remarkable his inability to determine with precision the contribution of medical progress to social welfare. They believed that policy for health should provide more preventive and curative services to individuals. They thought that general social policy should promote a higher standard of living. In the absence of a coherent theory for assigning priority in social policy, it was better to do more rather than less. The Hospital Committee of the British Medical Association, for example, recorded its satisfaction that Brend's book had received favorable comment from the press.


Health Insurance in the United States

The first crusade for state-mandated health insurance in the United States had a different result from the campaign for National Health Insurance in Britain. The coalition supporting the introduction of state laws mandating health insurance became smaller and narrower between 1914 and 1920. When the American Association for Labor Legislation began its campaign for health insurance, it had considerable support among doctors, philanthropists, and some leaders of organized labor. By 1920, a small band of intellectuals, doctors, and laymen, who gave priority to reorganizing medical services, were the most visible advocates of a program that seemed further and further from implementation each year.

The change in emphasis from cash to services among American advocates of compulsory health insurance occurred rapidly and without attracting critical attention. In 1914, a model insurance bill drafted by a committee of the American Association for Labor Legislation accorded priority to what it described as reducing destitution rather than to providing an explicit set of services. Two years later, however, a revised model bill gave priority to remedying the loss of wages due to illness. In 1921, Michael M. Davis, a social scientist who was, like William Brend, a prominent lay expert on health affairs, separated medical services from broad social policy. Sickness was the only cause of poverty that interested Davis. He saw no vicious circle of poverty and illness. In his view, adequate medical service could now relieve and prevent dependency. Americans, he asserted, should not emulate the British, who temporized about inefficiently organized medical care while they "foolishly" provided cash benefits. Comprehensive insurance in America, Davis maintained, should be deferred until medical care was properly organized.

When the AALL decided in 1914 that compulsory health insurance was the next great step in social legislation, it overestimated its political strength and underestimated the complexity of the issues involved in policy for medical care. The several thousand members of the AALL — most of whom were employed by universities, social settlements and service agencies, or by liberal magazines — were euphoric in 1914. What they called the first step, a campaign to pass laws in the states to compensate workers for job-related injuries, had been a striking success. Irving Fisher, a Yale professor of economics and president of the AALL, had written a stirring Report on National Vitality for the Committee of One Hundred, a group of industrial, political and religious leaders appointed by President Theodore Roosevelt. The prestige of social scientists and the civic responsiveness to their sense of mission had never been greater. In 1912, Woodrow Wilson, an academic political scientist, was elected president of the United States. Fisher's views, and those of many of his colleagues in the AALL — John R. Commons, Edward T. Devine, and Henry Seager, for example — were eagerly sought by the press and by public agencies.


(Continues...)

Excerpted from Health Policies, Health Politics by Daniel M. Fox. Copyright © 1986 Princeton University Press. Excerpted by permission of PRINCETON UNIVERSITY PRESS.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

Table of Contents

  • FrontMatter, pg. i
  • Contents, pg. v
  • Acknowledgments, pg. vii
  • Introduction, pg. ix
  • I. Health Policy and the Perception of Medical Progress: 1910-1918, pg. 3
  • II. Commitment to Hierarchy and Regionalism: Britain, 1918-1929, pg. 21
  • III. The Promise and Threat of Hierarchy: The United States, 1918-1933, pg. 37
  • IV. Strengthening Consensus: Britain, 1929-1939, pg. 52
  • V. Acrimony and Realignment: The United States, 1932-1940, pg. 70
  • VI. The Second World War and Health Policy: Britain, 1939-1945, pg. 94
  • VII. The Second World War and Health Policy: The United States, 1941-1946, pg. 115
  • VIII. Establishing the National Health Service: Britain, 1946-1951, pg. 132
  • IX. A Policy for Growth: The United States, 1946-1953, pg. 149
  • X. The Priorities of the National Health Service: Britain, 1951-1962, pg. 169
  • XI. A Triumphant Coalition: The United States, 1953-1965, pg. 188
  • Epilogue, pg. 207
  • Note on Sources, pg. 213
  • Index, pg. 227



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