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A history lesson in health care reform

A map of North America surrounded by a stethoscope, medicine capsules and medical syringe symbolizes health care reform in the U.S.

TEXT OF STORY

Kai Ryssdal: OK, so now the health care bill is officially done. I know you've heard that before, but President Obama signed the last package of legislative fixes at a ceremony in Virginia this morning. If it feels like we've all be talking about health care forever, man, you have no idea. Over the past year of this debate, there have been references to the Clintons in '93 and '94, Lyndon Johnson and Medicare in 1965 as well.

But to find the beginning of the U.S. health care debate, you've got to go farther back than that. From the Marketplace Health Desk at WHYY in Philadelphia, Gregory Warner reports.


[Knock on William Dubin's office]

Gregory Warner: Hi.

Dubin: Hey, how are you doing?

Warner: Great.

So this is a story I heard from a doctor that I met one time.

Warner: Can you introduce yourself to me?

Dubin: I'm William Dubin, I'm professor and interim chair at Temple University School of Medicine, Department of Psychiatry.

Bill Dubin is not only a psychiatrist. He's also an amateur historian, and he's got a book in his lap...

Dubin: Called "The Social Transformation of American Medicine" by Paul Starr.

...Which is where he read the following story. It's a story that begins at the turn of the 20th century.

Dubin: Well, what happened and the way this developed is, Europe now by 1900, 1905 now has compulsory health care insurance. The United States doesn't.

Now, it's 1912, and the progressives nominate Teddy Roosevelt to be their candidate in the presidential election.

["Symphonic Raps" by Louis Armstrong]

Dubin: And Roosevelt came out 100 percent behind compulsory health care insurance. And his actual quote was, no country could be strong if the people are sick and poor.

[Archival tape of Teddy Roosevelt's speech]

Dubin: Of course, Roosevelt lost the election.

["Two Deuces" by Louis Armstrong]

But the progressives weren't about to give up that easily. Remember, this was the Age of Progress, the time for child labor laws and worker's comp. Progressives felt it was time to change health care as well. So a group of economists and politicians and doctors, including Teddy Roosevelt's personal physician, got together to propose universal health insurance for the working class.

Dubin: This was the first time in the United States somebody actually put together a proposal, looking at health care. And the paper that came out said, "You know, let's pay the doctors and the hospitals, let's have insurance that will pay doctors and hospitals, sick pay, maternity and death benefits."

And they suggested a sliding scale, so the less your income, the lower your premium.

Dubin: Sounds familiar doesn't it? This was 1915, this proposal.

In 1915, penicillin hadn't been discovered yet, and pure mutton tallow was still the most popular cure for cuts. But the reform debate feels strangely modern. The progressives even grappled with the cost of care.

Dubin: They stated, and this was in 1916, that paying doctors for individual services would be too expensive.

Because paying doctors for each service gives them a financial incentive to do more.

Dubin: So let's give them a lump sum of money to take care of the patients.

Which is how it's done now at hospitals like the Mayo Clinic, or other so-called "high value" hospitals, which are models for efficient care.

Dubin: But it was proposed in 1916 as a way to get out of the cost of medicine, because the belief was that fee for service would lead to serious financial problems in the end.

Big business opposed reform, and so did labor unions, whose power to negotiate health benefits was their main recruiting tool for new members. And messing with how doctors got paid? Not a popular move. The American Medical Association, which had initially supported reform, now attacked it.

Dubin: Because they were concerned about income, and they were concerned about autonomy. And the positions of physicians really from the beginning of this country is, no one should ever come between us and our patients. Very similar to the arguments today.

Opponents of the reform effort came up with a strategy. This was in the years leading up to World War I. America was about to go to battle with Germany. And Germany had been the first country to pass universal health care.

Dubin: And they used this anti-German feeling as a way to attack compulsory health care as some insidious plot to undermine the American government and the American people.

Warner: So, they called them the dirtiest word you can call an American, which is a European.

Dubin: Right, and only in this time, there were various, "Germans," and "Prussians" and "doing the Emperor of Germany's work."

This became the pattern. When reformers tried to restart the debate in the '20s, they were called socialists.

Dubin: Right, and in Harry Truman's era, they called them Bolsheviks and communists. And that's the whole history of health care reform is, champions, they lose, someone picks it up again, champions it, they lose.

Until the day comes when they win.

In Philadelphia, I'm Gregory Warner for Marketplace.

About the author

Gregory Warner is a senior reporter covering the economics and business of healthcare for the entire Marketplace portfolio.

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