Northern Illinois University History Professor Beatrix Hoffman has a new book out that takes a fresh and intriguing look at the history of health care rights in the United States.
Despite the fact that nearly every other developed country in the world considers health care a right, passage of the 2010 Affordable Care Act in the United States was hard fought because of a staunch and vocal opposition to universal health care among many American lawmakers.
In "Health Care for Some: Rights and Rationing in the United States since 1930" (University of Chicago Press), Hoffman examines why the United States has been so divided on the issue. She offers an explanation in the form of an engaging and in-depth look at America's long tradition of unequal access to health care.
Hoffman, who serves as chair of the Northern Illinois University Department of History, is an expert in 20th century American history, with a specialization in medicine and social movements.
What follows is a Q-and-A with Professor Hoffman.
AMONG DEVELOPED COUNTRIES, HOW IS THE UNITED STATES UNIQUE IN REGARDS TO PROVIDING HEALTH CARE TO ITS CITIZENS?
Well, other countries provide health care as a right of citizenship, and we don't. All other industrialized countries have some form of universal health coverage, covering virtually 100 percent of their citizens, for a cost of about half of what we pay. The U.S. system is far more costly and leaves millions of people with no health coverage at all. Americans are the least satisfied with their health system.
The U.S. is also unique because the majority of health coverage is tied to employment, and because of the very large role of private, profit-making companies in the health system.
CAN YOU BRIEFLY ELABORATE ON WHAT YOU MEAN IN THE BOOK BY THE NOTION OF RATIONING? HOW IS THE UNITED STATES UNIQUE IN THIS REGARD?
Rationing is a hot-button term that in this country is mostly used as a scare tactic to mean the denial of health care. Opponents of reform argue that national health coverage will require denying people treatments to save money ("death panels"). This claim is just not true—many countries with universal coverage keep their costs down through budget negotiations with providers, not by limiting medical services. I argue that the U.S. has in fact always engaged in rationing, but that we ration care and coverage by ability to pay, by race, by employment, by age (e.g. Medicare), by health condition, and many, many other ways. We have to acknowledge that we already ration in order to carry on a constructive debate about how we can improve the health system.
WILL RATIONING CONTINUE TO TAKE PLACE UNDER THE AFFORDABLE CARE ACT?
The Act as it is written does not allow rationing by denial of treatment. Its most important achievement is that it will end rationing by health status, by no longer allowing insurance companies to deny coverage to people with pre-existing conditions. But in some other ways—by leaving many uninsured, by continuing to divide people into different eligibility types based on age (Medicare), income (Medicaid), employment, etc.—it continues the American way of rationing.
WHY DID YOU WRITE THIS BOOK?
My first book, "The Wages of Sickness," focused on the defeat of the first campaign for state-sponsored health coverage in the U.S., in the 1910s. I decided that for my next project I wanted to stop writing about what we didn't do (adopt universal health coverage) and instead tell the story of how the U.S. developed the health care system that exists today. Rather than looking primarily at the politics of health care reform in Washington, I wanted to look at how people have experienced American health care.
HOW IS YOUR EXAMINATION OF THE HISTORY OF U.S. HEALTH CARE DIFFERENT FROM OTHERS?
I tried to combine political history with social history, that is, tell the story from both the bottom up and the top down. The voices of patients waiting in emergency rooms are as important as the voices of U.S. presidents in my story. It's the first book to examine the history of American rationing, and how these practices developed and changed over time. I also wrote the book in a way that I hope appeals to non-academic readers as well as scholars.
HOW DID YOU GO ABOUT RESEARCHING "HEALTH CARE FOR SOME," AND WERE THERE ANY SURPRISES ALONG THE WAY?
I was very fortunate to receive an award from the Robert Wood Johnson Foundation that allowed me to conduct research in archives all around the country. In order to find records of ordinary Americans' experiences with health care, I had to look in some out-of-the-way places. For example, in a tiny county clerk's office in the mining town of Bisbee, Ariz., I found the complete transcript of an important law case that helped lead to the right to emergency care. Tuskegee University in Alabama has the records of a civil rights organization that documented hundreds of cases of people being turned away from hospitals due to their race, from the 1930s through the 1960s. One surprise was a cache of letters at the Reuther Archive in Detroit from senior citizens describing their experiences with the early Medicare system. They were so appreciative of their new health coverage, but they also talked about how difficult it was to pay for deductibles and other things that Medicare didn't cover.
But the biggest surprise of all was that the U.S. passed comprehensive health reform right before I completed the book. I had to write an entirely new epilogue!
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