Were the health policy questions different in 1932?

The 1932 Final Report of the Committee on the Costs of Medical Care began this way:

Pain, sickness, and bereavement have shadowed mankind throughout the ages; today there is a vast amount of unnecessary sickness and many thousands of unnecessary deaths.

However, the 44 member committee that spent 5 years studying (and 28 volumes documenting) the health needs of the population, and the organization, distribution and cost of health care services available during the 1920s United States imagined a better outcome.

Yet medical science has made marvelous advances during the last fifty years….We know how to do many things which we fail to do or do in an incomplete and often most unsatisfactory manner. As a result of our failure to utilize most fully the results of scientific research, the people are not getting the service which they need-first, because in many cases its cost is beyond their reach, and second, because in many parts of the country it is not available.

As I was was listening to Gov. Romney’s speech, I was flipping through the report and thinking about the 5 main recommendations of the Committee in light of the current debate, 80 years later.

  • …medical service, both preventive and therapeutic, should be furnished largely by organized groups of physicians, dentists, nurses, pharmacists, and other associated personnel…ACOs anyone!
  • …extension of all basic public health services-whether provided by governmental or nongovernmental agencies-so that they will be available to the entire population according to its needs…Calls to not ignore population-based public health, even as medical science was in its infancy!
  • …the costs of medical care be placed on a group payment basis, through the use of insurance, through the use of taxation, or through the use of both of these methods. This is not meant to preclude the continuation of medical service provided on an individual fee basis for those who prefer the present method….A cobbled system of financing medical care was imagined, and a cobbled system developed!
  • …the study, evaluation, and coordination of medical service be considered important…we need more research; obviously, some things never change!
  • …That the training of physicians give increasing emphasis to the teaching of health and the prevention of disease…we already needed more primary care providers before we had invented the term!

In a further foreshadowing of our current debate, 8 members of the committee saw fit to file a minority report. These 8 physicians primarily objected to recommendations 1 (organizing medicine) and 3 (expanding insurance financing through multiple means). On recommendation 1, they feared that the ‘industrialization of medicine’ would harm both their profession and patients. Their objection to moving ahead with a variety of voluntary and compulsory insurance arrangements is fascinating to me. In my words, they feared ‘no man’s land’; making it a priority to cover everyone, but not developing a predictable means of doing so.

…It seems clear that recommendations for further trial and expansion of voluntary insurance schemes in the United States are entirely inconsistent with the committee’s own findings [my insert: about inability of patients to afford care, while also worrying about the cost to society, when we spent 2% of GDP on health]….if we must adopt in this country either of the methods tried out in Europe, the sensible and logical plan would be to adopt the method to which European countries have come through experience, that is, a compulsory plan under governmental control.

It should be remembered that compulsory systems of health insurance in European countries are still under trial. There is still no convincing proof that under these systems the costs of medical care have been reduced nor that the new evils to which they give rise are preferable to those which they are supposed to abate….

And so it continues.

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