Health care, rationed all along

Health Care for Some

Rights and Rationing
in the United States Since 1930

By Beatrix Hoffman

University of Chicago Press.

336 pp. $30

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Reviewed by Paul Jablow

This much we know: The United States spends more on health care than any other industrialized nation. The outcomes are, for the most part, worse.

The questions this raises are "How did we get there?" and "Where do we go from here?"

Beatrix Hoffman, a history professor at Northern Illinois University, tells us something about the first and very little about the second. This isn't necessarily a criticism. No one else seems to have the answers, either. But a deeper look at how we got to where we are might give us some hints.

It is no secret that countries with universal coverage seem to get more bang for their health-care buck. And that attempts to bring such a system to the United States produce warnings of "rationing," "socialism" or, in its most emotionally charged form, "death panels."

Hoffman's case, which she makes persuasively, is that we've had rationing all along: usually by income, but sometimes also by age, occupation, or even disease, as in the political effectiveness of AIDS advocates.

"The American way of rationing," she writes, "is a complex, fragmented and often contradictory blend of policies and practices, unique to the United States. . . . The United States is also unique among affluent nations because it does not officially recognize a right to health care."

The right to health care was included in the 1948 United Nations Universal Declaration of Human Rights and has been supported to varying degrees by a series of presidents, including Theodore Roosevelt, Richard Nixon, Harry Truman, Bill Clinton, and Barack Obama, usually with the backing of human rights and labor organizations. It has been spurred by factors such as wartime and advances in medicine that make access to health care more of a life-or-death proposition than it was generations ago, when physicians could often do little more than look somber at the bedside.

But it has never been able to overcome countervailing pressures such as opposition by most of the medical profession and the insurance industry and, perhaps most important, by something in the American political character. Looking only at what the various players did is a bit like analyzing a region's agriculture by considering only the crops and not the soil.

Still, Hoffman's history can be a useful compendium to others' sociology.

In 1798, we learn, the federal government made its first foray into health care, establishing an insurance plan for Navy members and merchant seamen. This started a tradition of worrying less about a government role in health care when it's directed at members of the military. This is based on understandable gratitude to those who risk their lives for their country, or at least put their civilian careers on hold.

But as Hoffman explains, it can also be traced to the country's shock at the physical condition of the young men subjected to the draft, which otherwise might have gone unnoticed.

Truman, an Army officer in World War I, would cite this in his support for an increased government role in health care in the 1940s after his predecessor, Franklin Roosevelt, refused to include health care in the Social Security Act.

World War II had been the first war in which more American troops died from combat than from disease, but FDR, fighting to preserve the New Deal, was reluctant to open another front against the American Medical Association, which had first come out against national health insurance in 1920.

Truman was far more willing to wage the fight, but a general decline in his popularity and a campaign by the AMA, Hoffman says, reduced public support for national health insurance from 75 percent in 1945 to 21 percent in 1949.

The campaign against national health insurance foreshadowed the multimillion-dollar "Harry and Louise" campaign by the insurance industry against Clinton's proposed health plan in 1983 and 1984. Hoffman does touch on the role that the economic interests of physicians, insurance companies, and the pharmaceutical industry play, which can be distinct from the interests of patients. And given the current political environment of well-disguised and virtually unlimited campaign contributions, "Harry and Louise" could soon be seen as quaint.

Dealing with the current political situation, Hoffman points out that the Patient Protection and Affordable Care Act of 2010 - a.k.a. "Obamacare" - mentions neither rights nor rationing. But the rationing debate is sure to be rekindled if cost-cutting efforts by Medicare lead it to a tougher stance on what treatments it will and won't pay for, based partly on research that the act supports.

The alternative, however, could end up - however disguised - once again as rationing by income.