Every year, the sycophants of the mainstream media get to rub shoulders with famous attractive people (actors) and famous ugly people (politicians). The White House Correspondents Dinner is an orgy of self-congratulatory back-patting, which attendees lovingly refer to as “nerd prom.”
Well, the biennial Policy History Conference is not exactly prom, but it is definitely the nerd equivalent of some kind of major social event. Nerdstock? Wonkapalooza? If tax policy or brownfield mitigation is your bag, then you will surely be making your way to Albany, Frankfort, or whichever button-down cowtown the conference happens to be held in that year. This year Policy History rolled into the Midwestern idyll of Columbus, OH, as boozy participants wound their way through the cobblestone streets of the city’s historic German Village, clutching a Dirty Frank sriracha slaw dog in one hand and the tear-stained pages of the 1981 Omnibus Budget Reconciliation Bill in another.
Whenever ToM contributors attend such conferences, we keep an eye out for great panels and fascinating new research, which we share in semi-digested form with our readers. These are the next great books and journal articles and bathroom stall graffiti of tomorrow—today. With controversies over Obamacare and the VA swirling in the public sphere, there could be no better time to bring much-needed historical perspective to the chronic problems of US healthcare. In these four enlightening papers, Jessica Adler, Tamara Mann, Zack Smith and Richard Scotch help us understand how we got to the terminally weird place we find ourselves in with the reportedly “greatest healthcare system in the world.”
Jessica Adler, “Burdens of a Great War: Making the U.S. Veterans’ Health System”
At a time when the dysfunctional and disgraceful treatment of America’s veterans has finally been making headlines, Florida International University’s Jessica Adler reminded listeners that the veterans’ health service is the largest integrated health system in US. Indeed, as ToM has pointed out many times in its coverage of the armed services and military families, the military has been among the most “socialist” of American institutions for decades, bringing important policy and political questions to bear when it provides healthcare, housing, and other necessities of life to servicemembers. Treatment of veterans, though, has often been socialism on the cheap, and, as Adler makes clear, the problem of caring for veterans has been deeply bound up with tropes about dependency, rehabilitation, and self-reliance that have long shaped American discourses about the welfare state.
As the United States began to craft the beginnings of a national system for veterans’ health after World War I, it did so not only out of concern for those who bore the scars of battle, but also because of the failure of prewar policies that aimed to guard against long term obligations to veterans. The Great War created a vast number of newly injured and traumatized soldiers who needed care, and the existing infrastructure for providing care proved truly inadequate. The spectre of the Civil War loomed over such debates, as the pensions and services provided for surviving veterans of America’s bloodiest conflict provided a cautionary tale of how to handle care for servicemembers. American policymakers, in essence, had to figure how to thread the needle of providing care for veterans without creating a permanent class of dependents—a struggle that ironically ended up producing the United States’ first fully national system of healthcare, the VA system.
The VA system grew in fits and starts from a faith in the power of government and medicine, a policy remnant of the Progressive Era of the early twenty-first century. Soon after the American declaration of war, policymakers expressed fear that shellshocked and maimed veterans would live in poverty, or persist on pensions like veterans of the Civil War. At the time, veterans had access to ten nationally sponsored soldiers’ homes for what was known as “domicile care,” i.e. nursing homes for those with nowhere else to turn. Such programs as pensions and soldiers’ homes were viewed as costly and unproductive in 1917, and reformers aimed to create a system that could cure veterans’ ailments and set them on the path to rehabilitated independence—avoiding an expensive and socially-stigmatized condition of long-term dependency. Policymakers increasingly supported a truly universal program, in which the military would oversee care until “maximum curative results” were achieved.
In military hospitals, some of those with lingering battle injuries reported having good experiences, but others complained about arcane rules regarding discipline and discharge. As soldiers, patients were still expected to abide by the chain of command and acceptable rules of conduct. At Walter Reed a soldier alleged that he was placed in a ward alongside patients with infectious diseases as punishment for leaving hospital grounds without permission. Furthermore, he said, hospital officials refused to deliver his mail. In a Colorado hospital, some patients were placed in straitjackets for insubordination — acts such as speaking inappropriately to an officer or sneaking tobacco into a disciplinary ward. Such incidents were made public in Congressional testimony, raising the question: should patients be treated as soldiers who ought to be obedient, or as wounded and venerated public servants?
Moreover, when should soldiers be released? Many wanted to be released as soon as possibles to go home, or escape the discipline of the hospital, while others feared lack of follow-up care or a guaranteed income. Incredibly, Army officials said that soldiers should be released when treatments were not working or they were apparently getting worse because of the “depressing” atmosphere of the hospital—quite the opposite of what we today would consider the ideal conditions for discharging someone from the hospital. Far from cruel or heartless, their perspectives were grounded in pragmatism: funding for army medical care and institutions dwindled as the war faded from public memory. In 1919 Congress mandated that different federal agencies should work together, but the resulting makeshift system was rife with problems. Veterans argued that they were subject to poor conditions and treatment at the hands of underqualified doctors, and newspapers brought attention to their complaints.
In response to the outcry, the federal government moved toward a more universal and systematic program of veterans’ care. Policymakers, public officials, and veterans’ advocates justified the idea in practical, not only humanitarian concerns. Veterans posed a “great public health problem,” and “economic savings” could be had by treating soldiers. In this view, Adler pointed out, “Federal aid could actually encourage self reliance.” Meanwhile, veterans organizations swayed Congress to pass far-reaching legislation, policies aimed at “treating all the necessities of the disabled man.” The program would not be a “new and unwarranted expansion of government,” supporters believed, because the proposed bureau would reduce costly redundancies, in which veterans ended up getting payments from more than one agency. The veterans’ health system would be justified in classic American terms of productivity and dependency, since government assistance could inspire veterans to come back take their place as productive citizens. Such entitlements, it was noted, could also ward off socialism and bolshevism.
In 1921 Congress set up the Veterans Bureau, which would be independent under the president. Critically, the new agency would fund treatment for battle injuries as well as conditions that were aggravated by service. Two key provisions meant that preexisting institutions could be transferred to new bureau and, if proper facilities were not available, the bureau could build its own. In the end, the veterans’ hospital system was never intentionally created but that was effect; local chambers of commerce and other constituencies approached the federal government to get their own hospitals, and 40 veterans hospitals were scattered through country by 1924. And by the 1930s, the vast majority of those treated at the hospitals did not have conditions related to service. Long before Medicare, the United States got its first “universal” public healthcare system (for some, anyway) almost by accident, and all in the name of warding off socialism and government dependency.
Tamara Mann, “Dependent, Not Old: The First National Conference on Aging”
In 1950, the first national Conference on Aging took place in Washington, DC, aiming to deal with “the problems incident to our increasingly older population.” In retrospect, it was a profound way station on the journey to what we now know as Medicare, which is arguably the outer limit of American social democracy thus far (no offense, Medicaid and ACA). In this paper, Columbia University’s Tamara Mann looks at the 1950 National Conference, arguing that it helped frame the concept of “old age” as a public policy and political problem, in contrast to earlier notions that centered on ill health or infirmity. In other words, whatever kept potentially productive people out of the workforce had been the key problem facing policymakers, not merely old age itself. Traditionally, experts had claimed that such problems could be explained through the idea of dependency (see veterans above), and focused on solutions to make the elderly productive and financially independent.
However, the elderly in the 1950s and 1960s faced increasing poverty, due in large part to mounting healthcare costs. In 1947 Truman appointed Oscar Ewing as Federal Security Administrator. Ewing believed the Korean conflict would remind people of the need for the elderly to work in order to support the war effort. Policy thinking about the aged at the time revealed a preoccupation with “usefulness,” “health maintenance,” and “rehabilitation.” According to Mann, conference participants were guided by six main assumptions: namely, that health is relative and can be improved; health should be optimum; aging is not solely chronological, but a reflection of health of the individual; the biggest threat was progressive impairment of health as one aged; the elderly should not be segregated from society; and public policy should set up no new and separate machinery for the elderly. In this view, early intervention was key, rather than treatment at the end of life. Public policy should focus on creating the well person, not coping with the sick one.
Despite this context, Ewing proposed a hospital insurance program for the elderly—an early version of what would become Medicare. He did so, because he believed it would be the first step toward securing national health insurance.
By the end of the conference, attendees conceptualized old age as ill health and dependency, believing that the elderly needed early intervention and retraining for work. The conference gave momentum for an early, limited version of national insurance. The elderly might have helped fight the American Medical Association, long-time opponent of universal healthcare, because there were more old people than doctors; indeed, the Washington Post was among the first to speak of the elderly as a voting bloc. Ewing believed Social Security beneficiaries would be the first recipients of national insurance. Universal healthcare advocates resisted this limited idea, but ultimately came around to what they considered the “political thing to do.” Indeed, Ewing and his allies built an “issue majority” on the support of the elderly, avoiding the main objections to universal insurance, i.e. that it was for the undeserving; that it would swell med system beyond capacity; and that it would lead to excessive control of physicians. The plan sought to provide “old age & survivors insurance” and avoided means testing (as we now see in Medicaid and Obamacare) by extending insurance protection to Social Security recipients.
As leading social scientist and civil servant Wilbur Cohen put it, it was “all very Hegelian.” Universal healthcare was the thesis, the AMA was the antithesis, and what ultimately became Medicare was the synthesis. Critics decried Ewing’s plan as “a New Deal vote-catching trap,” which would “encourage imaginary illness and malingering,” according to the Chicago Tribune. (As the University of Oregon’s Jim Mohr pointed out during the panel, the Trib was the mouthpiece for the AMA at the time.)
In the end, Truman gave Ewing permission to go forward with the plan but did not really put his weight behind it. In 1953 the outlook for expanding the welfare state was bleak: reformers would get neither national health nor coverage for the aged. What did not end, however, was pressure for Medicare. President Eisenhower did not see the political potential of the elderly, yet between 1953 to 1963 health costs doubled and doctors’ fees increased 37%. A new group, the National Council of Senior Citizens, began pushing the idea of health insurance for the elderly, and the AMA had to battle with an organized front of seniors for the first time. The ultimate result was the 1965 passage of Medicare, which is today the sacred cow of both those who support the welfare state and those who want to destroy it—a clear example of the long game of policy and the grinding realities of interest group politics.
Zack Smith, “‘The Moral Equivalent of War’: Dick Armey, Bill Kristol, and the Republican Fight against the Health Security Act”
Progressives may have felt like their wings were seriously clipped during the debate over the Affordable Care Act in 2009-10. That latest attempt to achieve “universal healthcare”—or something approaching it—resulted in an extraordinarily complex system of private insurance that frustrated liberals and conservatives alike. Liberals, though, felt that their historic moment of opportunity following the election of President Obama and a Democratic supermajority should have resulted in a more ambitious expansion of the social welfare state. In this paper, Jackson College’s Zack Smith helps explain why that didn’t happen.
Democratic reformers, of course, ran into a buzzsaw of conservative opposition in 2009, and this strategy of uniform, massive resistance has its roots in the collapse of President Bill Clinton’s healthcare reform effort. More to the point, strategists such as House Minority Leader Dick Armey and conservative “intellectual” Bill Kristol successfully convinced their GOP allies to withdraw any cooperation with the reform project. Some Republican lawmakers felt like the writing was on the wall—some kind of reform was going to pass, and it thus behooved them to get on board in one way or another. Kristol, in particular, cautioned conservatives against signing on with a new entitlement that could legitimize the the Democratic Party’s philosophy of the welfare state—in short, another “New Deal vote-catching trap,” as critics of healthcare reform put it in the 1950s.
Kristol’s strategy seems old hat now, since massive resistance has become the GOP’s natural reflex in the Tea Party era. But this sort of unstinting partisanship was not always the case. Indeed, Republicans at least flirted with the idea of cooperating with Clinton, and some felt that the GOP should come out with its own plan. Healthcare reform was in the air in 1992. As Smith points out, “it’s the economy, stupid” may have been Clinton’s top slogan, but people forget that “don’t forget healthcare” was one of his campaign mantras as well. Even Newt Gingrich, incredibly, was not committed to total opposition at first. What Kristol intuited was that Republicans could be against the plan without being against universal coverage, which seemed miserly and mean. In the memo “The Moral Equivalent of War,” he recommended a sort of war of attrition—if Republicans could drag out the process long enough by denying Democrats any kind of cooperation, the details of the plan would become better known, raising doubts about the program’s bureaucracy and complexity. Instead of being the opponents of universal healthcare, the GOP could be the defender of middle-class interests against a heavy-handed, inefficient federal government.
Kristol, for once in his life, was right. Gingrich may have initially thought that “being against everything” was “nuts,” but Smith argues that Republicans were wise not to put forward their own plan. Preparing a GOP plan would have distracted from the specifics of Clinton’s proposal and, in fact, legitimized the idea that the healthcare system needed reform. In turn, the failure of healthcare reform was a setback for the entire concept of “big government liberalism”—the notion that government could and should step in to solve problems like access to healthcare, or poverty. Reform was deferred for the better part of a generation, or what felt like one. By the time President Obama pursued universal healthcare fifteen years later, he and fellow Democrats started with a more limited, market-oriented plan that they thought would more amenable to Republicans—only to discover that the GOP had learned the lessons of 1994 all too well.
Richard Scotch, “Care in the Community: The Campaign by People with Disabilities to Shift Care Away from Nursing Homes”
People with disabilities are America’s largest minority group, argued Richard Scotch, a policy scholar at the University of Texas at Dallas. They are more numerous than African Americans, Hispanics, or even seniors. Many people with disabilities face needs for healthcare as well as personal assistance, but Scotch cautioned that these two become conflated and often lead to unnecessary medicalization or hospitalization. Most prefer home- or community-based services, but public and private insurance policies tend to be biased toward service in medical settings.
Scotch’s paper, thus, was an outlier on the panel, in the sense that Adler, Mann, and Smith were talking about people who wanted more healthcare (or access to healthcare, period)—veterans, seniors, the uninsured. Members of the disability rights movement were, in a way, seeking less. Put differently, people with disabilities felt like their needs weremedicalized in a way that benefited interests such as the nursing home industry more than members of their community. Scotch pointed out that people with disabilities are more likely to be unemployed or underemployed, earning lower wages (about 2/3 of what the nondisabled make) and experiencing poverty rate at twice the rate of the general population. Prior to the Affordable Care Act, many could not even acquire insurance, since medical underwriting excluded preexisting conditions, and those that did have insurance often got it from Medicare or Medicaid. Their care was often controlled by professional gatekeepers in residential settings; in fact, more than half of Medicaid funding goes to fund long-term care, often in nursing homes.
Medicaid has been historically biased toward care in institutions, emphasizing inability and medical impairment. This is due in part, Scotch suggested, due to the political power of nursing home industry, particularly at the state level. Advocates, on the other hand, have long asserted that people with disabilities prefer to receive home services, which allow them to exercise greater control over services received, particularly personal care services (versus strictly medical services). In 1981 Congress responded to such concerns by giving states the option to use Medicaid funds for case management, adult daycare, support services, home healthcare, and personal care.
States, however, vary in how much they have embraced this freedom. In a key 1999 case, two disabled women requested community placement in Georgia but were denied; writing for a majority on the Supreme Court, Justice Ruth Bader Ginsburg determined that they had right to live in their own community rather than a residential institution. The high court also held that states did not have boundless responsibilities, however; requests for home or community case had to be balanced against the availability of resources and infrastructure. Moreover, people with disabilities tended to get more rhetoric than resources on this issue. Texas Governor George W. Bush had a lot to say about the Supreme Court’s decision but ultimately did not do much. As Scotch argued, it is actually easier to cut budgets for institutional care while funds for community care are not commensurably increased.
In his paper Scotch provided a brief but fascinating history of the independent living movement in the late twentieth century. The movement grew out of disability rights advocacy in the 1970s and aimed to maximize peer and self help services; its thesis was that individuals should control their own care and receive it in a home or nonmedical facility. Their slogan was “Nothing about without us.” The movement had some success in the 1970s, particularly in pushing reform of vocational rehab programs, but it ultimarely fared worse in terms of affecting the way most state and federal healthcare services were delivered. Disability advocates continued to run up against resistance from medical gatekeepers, as doctors, hospitals, and nursing homes controled treatment.
The story of ADAPT symbolizes the triumphs and travails of the disability rights movement. The group evolved from the Denver-based organization Americans Disabled for Accessible Public Transit. Activists exercised civil disobedience, chaining themselves to buses to demand better access to transit. Group members attended conferences in the transportation industry around the country and drew attention to their concerns. Scotch suggested that their activism might have helped contribute to the success of the landmark Americans with Disabilities Act of 1990. After passage of the ADA, the group shifted its focus to the problems of people living in nursing homes, brandishing the slogans “Free our people” and “Stolen lives.” They demonstrated at state legislatures and conference and managed to get the issue of community-based treatment on the public agenda, even if their policy preferences have not, for the most part, been adopted. Today, the movement faces new and different issues, such as the devolution of Medicaid decisionmaking to state level. The Affordable Care Act includes some valuable provisions for people with disabilities, most notably the ban on denying coverage due to preexisting conditions; thus, many people with disabilities may move on to the private insurance market. However, powerful financial intermediaries, such as insurers and state governments, might actually be amenable to cost-saving benefits of community-based care, but far less concerned about consumer rights. As always, Scotch concluded, more activism is needed.