Truman and the medical profession: replay or lesson for the nineties.
Immediate demobilization became the battle cry of the American people after World War II ended. American soldiers wanted to get back home, get back to work, and start families after being overseas for up to five years. However, unless one was fortunate enough to be covered by a contract, typically negotiated with labor unions (which were much more powerful in the forties), little health insurance was provided to the returning veterans when they joined the workforce. Even so, this was a far better situation than existed prior to World War II: "In 1949, the total national expenditures for medical care of civilians amounted to about 10.6 billion dollars or $70 per person, in contrast to about 3.6 billion dollars or $30 per person in 1929. These expenditures represented 4.9% of the national income in 1949 against 4.4% in 1929.... At the end of 1949, programs of public medical care were available to more than 25 million persons, voluntary medical insurance plans to about 66 million persons, and social insurance programs to close to 40 million persons.... (These) constitute more than half the civilian population.... (T)he increase in coverage during the period 1930-50 is extraordinary.... (However) comprehensive medical care, including preventive services...is furnished to a few million persons only."(1)
Fear of Communism
At the same time that American soldiers returned from war in Europe and Asia, the U.S. government developed a policy of containment as it reacted to Stalin's aggressive moves toward Eastern Europe. While many Americans wanted to simply get on with life, a substantial number of individuals involved themselves in a frenzy of attempting to root out any evidence of Communism in American society. An uncannily similar campaign against NHI occurred during World War I. As pointed out in the first article in this series,(2) during the first World War, the Germans were attacked for everything they stood for, including their national health system. It was irrelevant that the British also had recently instituted such a system.
The anti-Communist hysteria, which reached its height under McCarthyism, spilled over into the debate over Truman's NHI proposal. Unfortunately, the American Medical Association played into these fears, especially with several of its offshoot organizations, notably the National Physician's Committee. This group, a front committee for the AMA containing many of its most right-wing members, began its position paper in opposition to Truman's health care proposal as follows:
"Compulsion is the key to Collectivism.... Almost hidden in the careful verbiage of the proposed legislation is the cold steel move to place in the hands of appointees of the Federal Government sole and exclusive responsibility for the distribution of health care for one hundred ten million people. In no country has machinery been established more sweeping in its provisions to serve the purpose of a Collectivist State.... On the one hand is the American concept of the inherent rights and sanctity of the individual--the human being. Government exists merely to serve the individual who authorizes and supports it. The result is our Freedom of Enterprise Society. On the other hand is the materialistic doctrine of the Totalitarians. Their basic tenet is the ultimate supremacy of the State, with the individual solely to serve. They deny the existence of God and deprive man of dignity and separate status....
"Compulsion is the key to Collectivism. If the Wagner-MurrayDingell proposals were enacted into law, they would introduce a compulsory tax to pay for a compulsory service-medical, dental, and nursing care--directly affecting the most vital and most sacred function of each individual citizen of the United States. If such a basis of centralized control is once established, Freedom can never be regained. In consequential time our Freedom of Enterprise institutions would be destroyed and concepts which have made America what it is, and we as a people what we are, would be forfeited. "Awake America!!"(3)
Fifty years later, editors of primary care journals are trumpeting the same criticism of government involvement in health care.(4) Even if these comments were true, they offer little as a solution to the health care crisis-other than untested paeans to the free market. I have no problem working within the free market as long as we recognize that many aspects of health care do not conform to free market principles. We need to work with these nonconformities and make appropriate adjustments in our health care plan.
The AMA's tactics played into the hands of the Republican majority in Congress, which Truman had to contend with after the midterm congressional elections of 1948. Charges by Representative Harness of socialistic tendencies within the Social Security Board were typical of the time. His views were summarized in an October 1947 article in Reader's Digest entitled "The Special Health Mission to Japan--Are We Imposing Socialized Medicine on the Japanese." According to Harness, the purpose of the mission was to "force upon that country a compulsory system of socialized medicine.... (The personnel on the mission consisted) entirely and exclusively of men long identified in the public record as advocates and proponents of socialized medicine not only in the United States but throughout the world. For many years strenuous efforts have been made to fasten a system of socialized medicine upon American physicians and upon the American people generally....Unsuccessful on the domestic front, American apostles of socialization have turned their eyes to foreign lands."(5)
Figure 1,[TABULAR DATA OMITTED] page 4, provides a summary of Truman's 5-Point Program on health, given as a message to Congress on Nov. 19, 1945. While most of the elements of Truman's proposal were never enacted, the recommendation pertaining to hospital construction, the Hill-Burton Act, was passed in 1947. This law has provided much of the funding for new hospital construction in this country In addition, though clearly a stop-gap measure, advocates of the uninsured have been able to use provisions of the Hill-Burton act to encourage hospitals to provide care to the uninsured.
The President's health care advisors worked out their proposal to the detail of proposing a staged enactment for national health reform. In a memo from Margaret C. Klem, a key economist within the Social Security Board, to I.S. Falk, a principal architect of Truman's plan and former director of research for the Committee on the Costs of Medical Care,(6) the following phase-in for different services was proposed:
1. All physician services, hospitalizations, and expensive prescriptions.
2. Home nursing and dental services.(7)
The same memo, prophetically entitled "The Timing, if any (emphasis added), in the Provision of Services Under a National Health Insurance Plan", advocated that, if push comes to shove and only one service can be initially enacted, physician services should be the first to be put into place.(7) Congressional Hearings The tenor of the heatings on the various bills submitted by the Administration during the Truman period reveals the impact of the Cold War.(8) Senator Robert Taft described the Wagner-Murray-Dingell bill as the "most socialistic measure that this Congress has ever had before it." In return, Senator Murray accused Taft of being a liar, a grandstander, impertinent, and insulting. Despite the absence of any threat from the former Communist states of Eastern Europe, advocates of free market approaches up to and including President Bush have characterized proposals advocating increased government regulation such as the Canadian model as replicating the failed policies of Eastern Europe.
A second attempt at introducing national health reform occurred in 1947. While many of the essentials remained, the administration made the following significant changes(9):
* Coverage was extended and included all civilian federal employees, recipients of old-age assistance, and aid to blind and dependent children plus their dependents.
* Administration of the act was to be under the National Health Insurance Board. However, the actual administration was to be performed at a local and state level.
* The bill tried to remove several objections made by the AMA by making more explicit the guarantees of professional rights of doctors, dentists, and hospitals and emphasizing the patient's right to a free choice of physician.
However, this bill also was never reported out of committee. Truman tried to go above Congress and called for a "National Health Assembly" similar in its composition (i.e., liberal) to that held during the Roosevelt administration. Oscar Ewing, the Federal Security Administrator and an active participant in the Roosevelt conference, presided over the meeting, held May 1-4, 1948, and submitted recommendations to Truman that were arrived at the meeting. Needless to say, they were supportive of the Truman, and, just as obvious, the AMA and many other interest groups were opposed.
Following, his victory in 1948, President Truman introduced a bill virtually identical to that submitted in 1947. The AMA cranked up its political machine and, with the assistance of a special financial levy on AMA members, mounted a massive lobbying campaign against national health reform. (The poster developed for this campaign is shown in figure 2, page 6)[TABULAR DATA OMITTED]. The bill was referred to the Committee on Labor and Public Welfare, where it died. In response, President Truman sent another special message to Congress requesting passage of a comprehensive national health reform proposal. This bill also never made it out of the Senate Committee on Labor and Public Welfare or the House Committee on Interstate and Foreign Commerce.
While Truman's efforts to enact national health reform are well known, legislative rebuttals to the Truman proposals are less so. Senator Taft submitted S. 2143, which would have provided primarily for an expansion of the Public Health Service to increase medical and dental care for uninsured and low-income individuals. These federal grants-in-aid were to be provided to the states "for broadening the distribution of their medical and hospital services to a point where these services are available to all families and individuals unable to pay the whole cost of such service."(10) This bill, submitted in 1946, was reintroduced several times over the next few years, but was never reported out of committee.
The battle of the polls that now characterizes the political scene also occurred during the Truman era. It is important, however, to disentangle the results to determine areas of agreement (which are present) and paint a picture of American public opinion on national health reform in the '40s.
Surveys were performed by the National Physician's Committee (NPC, representing the AMA) and the National Opinion Research Center (representing the Physician's Committee on Research, PCR, an organization in favor of national health reform). The key questions in the surveys pertained to the degree of support for using the Social Security Law to fund national health reform. The NPC survey found only 16 percent in favor of using the Social Security trust fund as a finance mechanism; 53 percent were opposed and 31 percent were undecided. The PCR survey found 41 percent in favor, 39 percent opposed, and 20 percent undecided.
While there is substantive disagreement in the polls on the advisability of paying for these services using federal funds, there was general agreement on the following question: "Are there any people in the United States who can't afford to see a doctor as often as they should? Would you say there are a great many people like that, or only a few?"(11)
In the aggregate, 57 percent were in favor, 36 percent were opposed, and only 7 percent indicated indecision. There are many other items that indicate that Americans living in the '40s believed that wider health insurance should be available at low cost. The conundrum facing policymakers during the Truman era, as it is today, was whether coverage should be federally mandated and funded or whether it should come from the private sector. In many ways similar to the situation confronting us today, public opinion is undecided; what is clear is that something needed (and needs) to be done. In a summary analysis of the two polls discussed above, the National Opinion Research Center concluded: "In fairness to the National Physicians' Committee and Opinion Research Corporation, and as a scientific finding of both surveys, it should be called to the reader's attention that public opinion regarding payment for medical care is still not crystallized. Many people are not convinced whether or not they want to be insured against doctor and hospital debt and, if so, whether they prefer private or government coverage.(12)
In the final analysis, polls will not provide us with any guides as to the specifics of American's preferences. They may not even provide us with information on whether Americans prefer increased regulation in lieu of the free market perspective. Rather, it appears that, as in the Truman era, the situation will be decided by interest groups confidently asserting that they speak on behalf of American public opinion.
The Role of Blue Cross
While many have pointed to the AMA as the ultimate culprit in the defeat of national health reform, the reality is that the American middle class realized that it had an alternative. As polls have shown, Americans, then and now, feel ambivalent about significant government involvement in their lives. The alternative to Truman's health plan was state-based Blue Cross plans. These voluntary health insurance plans exploded in popularity after the end of World War II. By 1946, more than 20 million Americans had enrolled in state wide Blue Cross plans for hospital care. Many of the founders of these voluntary health insurance programs were leaders of the compulsory health insurance movement in the 1930s. By the forties, these individuals were executives in the Blue Cross movement and enjoyed significant political leverage. Presaging Blue Cross opposition to national health reform, C. Rufus Rorem declared in congressional testimony: "We are anxious to expand its (Blue Cross') virtue and remove its defects and thus increase its services to our nation. We believe it should not disappear from the American scene as a noble experiment."(13)
Other Interest Groups
The necessity of significant support by key interest groups constitutes a persistent historical theme in efforts to enact national health reform. A partial listing of the wide range of interest groups either partially or completely opposed to various forms of the Wagner-Murray-Dingell legislation provides ample explanation for the difficult, ultimately impossible, hurdle Truman had to overcome in his efforts to enact national health reform.
Completely opposed: American Bar Association, U.S. Chamber of Commerce, various hospital associations. Opposed to significant portions of the bill: National Conference of Catholic Charities, National Grange American Farm Bureau, Blue Cross, Association of State and Territorial Health Officers, Children's Bureau. Supportive with significant amendments: NAACP, American Nurses Association.(14)
It is important to provide an account of the AMA's activities in part as an indication of the loss of power that the AMA has suffered since that time. Just as important, however, one can view the AMA from the perspective that its work during the Truman era was successful as long as other major interest groups were not in opposition. The AMA plan from the Truman era is summarized in figure 3,[TABULAR DATA OMITTED] below. In many ways, the AMA position has not changed dramatically since the Truman era. The AMA continues to be extremely wary of government involvement in the health care system.
Examining the issue of government regulation and involvement from a different perspective, it is instructive to compare the practice preferences of physicians immediately after World War II with those of today and contrast these preferences with the AMA's consistent political position on this issue. If one believes the AMA, physicians have always preferred solo fee-for-service medicine. The reality is quite different, even as far back as the Truman era.
"[During World War II] the armed forces absorbed one-third of all the active U.S. doctors....as VE-day approaches, the whole issue [of national health reform] is rising again." Doctors are among those helping to raise it. Those now in the armed forces look forward not to simple reconversion, but to a large extent to medical reform. Recently, an AMA committee asked doctors in uniform to indicate whether they would want to enter government service or private group practice after the war. Replies reported by the AMA show that 30 percent of the older men, who have now had opportunity to compare practice under the traditional structure with group practice for the government, want full-time jobs in government service. Moreover, 53 percent of doctors of all ages want to go into the group form of private practice. Considering all age groups, 63 percent indicate a preference for a form of practice other than the traditional form of solo practice on a fee-for-service basis.(15)
Despite these physician preferences for nonsolo fee-for-service practice, the AMA actively discouraged physicians from participating in medical practice the AMA did not feel was in the medical profession's best interests (i.e., prepaid health plans). As I am sure many Physician Executive readers with relatives who are physicians will recall, there was a great deal of pressure on physicians not to join prepaid health plans. In the early fifties, my father, a recent immigrant to this country, was offered employment at the Kaiser plan in Los Angeles. He turned it down after feeling pressure from the county medical society.
The Truman period illustrates the power of the Presidency, the unbending opposition of the medical profession, and the American public's relative contentment with voluntary health insurance. While the medical profession was noisiest in its opposition, it had in its company powerful interest groups whose support for any major health reform legislation was vital. One might argue that the framework of the debate now and that in the Truman period are very different. Yet the fundamental debate is still the same. We are still arguing whether health care should remain primarily in the private sector or should succumb to the increasing encroachment of the public sphere.
In confronting this debate, the medical profession has two options. It can propose alternatives, such as the one outlined by the American College of Physicians, which will ensure a place for the medical profession at the head of the health care delivery table. Or it can stick its head in the sand as the American Medical Association did under Truman. In the short term, private sector solutions, such as managed competition, may very well win out. Over the long term, there is no question that a partnership will have to be defined between the government and the private sector. Ideally, the medical profession will have the leadership to place it at the head of the dinner table conversation discussing national health reform.
1. Goldman, F. "Major Areas of Achievement and Deficiency." Journal of the American Economic Association 1951, pp. 627,629,631.
2. Goldfield, N. "Efforts to Implement National Health Reform in the United States." Physician Executive 18(2):23-7, March-April 1992.
3. National Physicians' Committee. "Compulsion, the Key to Collectivism," 1947, p. 3.
4. For example, see monthly editorials of the editor of Postgraduate Medicine.
5. Unsigned editorial in Reader's Digest, October 1947, as quoted in appendix provided in a letter of A.J. Altmeyer to Marion Folsom of Eastman Kodak, Jan. 10, 1949, Reprinted from the National Archives.
6. Goldfield, N. "The AMA Faces Down FDR and Wins." Physician Executive 19(1):3-8, Jan.-Feb. 1993.
7. Memo from Margaret C. Klem to I.S. Falk. The Timing, if any, in the Provision of Services under a National Insurance Plan, Dec. 22, 1948.
8. Hearings on S. 1606, National Health Program, U.S. Senate, Committee on Education and Labor, 79th Congress, 2nd Session. Washington, D.C.: U.S. Government Printing Office, 1946.
9. S. 1320, The National Health Insurance and Public Health Act. Congressional Record, vol, 93, part 4, 80th Congress, 1st Session, p. 5517.
10. Glasgow, J. "The Compulsory Health Insurance Movement in the United States," a PhD dissertation, 1965, p. 162.
11. "Report of a National Public Opinion Survey of Civilian Adults," conducted in Aug. 1944 for the Physicians' Committee on Research/Inc., by the National Opinion Research Center, University of Denver, Oct. 1944, p. 7.
12. Ibid., p, 5.
13. Rorem, C. A Quest for Certainty: Essays on Health Care Economics. Ann Arbor, Mich.: Health Administration Press, 1982, pp. 99113.
14. Glasgow, op. cit., p. 176,
15, "United States Medicine in Transition." Fortune, Dec. 1944, p. 157.
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|Date:||Mar 1, 1993|
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