Transcripts For CSPAN3 Health Care Policy Since World War I 20240714

Topics include the roots of the modern Health Care System, the medical bills transformation into a business, and disparities in insurance coverage. The Natural History Center Hosted the event. I think we will try to start the event on time. My name is dane kennedy, director of the National History center. I want to welcome you all to this briefing of the history of u. S. Health care and health care policy. This is a briefing sponsored by the National History center, which is affiliated with the american historical association, and is part of a series of briefings that we offer that provide historical perspectives are issues that are currently confronting congress. We will have another one at the end of next month which would be a history of u. S. Iranian relations. I should stress that these events are strictly nonpartisan, they are not intended to offer any kind of policy recommendations or agendas, they are simply met to give greater insight to how we got to where we are, which we believe helps us to understand how we can solve problems. A few things, that i will turn it over to alan. First of all, the. Carnegie Mellon Foundation funds this program. We are very grateful to them. Secondly, a room has been booked for us by congressman gerry connollys office, and we are grateful to them. I would also like to thank my assistant director jeffery gardner, who is in the table outside and will be coming in shortly. Now we turn it over to professor alan kraut from the American University who will moderate the event. Me say, mostthat of you will find these index cards on your seat. That asnt of these is the discussion proceeds, if you have questions, write them on these cards and we will collect them after formal remarks and use them to initiate the discussion. All right . Think about that as they are giving their remarks. Alan . Dane. Thank you, good morning. In 1941, the influential declared henry louis that in his view, the 20th century would be the american century, a time when american achievements and influence would outdistance those of other countries. In no field was that more accurate than in the medical science industry, in discovery and research and vaccine development, and surgical innovation, the United States was and remain medical heroes abounded. A heart surgeon performed the first coronary bypass operation in 1964. Thomas, sometimes called the father of modern transplantation performed the first human liver transplant in 1963. The father of modern transplantation performed the first human liver transplant in 1963. Then there was the miraculous benefits of the human genome project at the National Institute of health. The problem is that the wondrous results produced by american researchers, surgeons, epidemic fighters, was not always accessible but the American Population broadly and equitably. Too often, health care in the United States was among the privileges enjoyed by the sealthy for in postwar american who had access to a Good Health Insurance policies, many purchased in the workplace. After the birth of the blues in the midcentury, and of course, i mean the cross and blue shield labor unions and private, employers negotiated medical plans for their employees. However, as the cost of medical care escalated, the number of middleclass americans who could afford Good Health Insurance declined. Many employers prefer to negotiate salaries with employees, but not medical benefits, because of climbing costs. Increasingly, many in the middle class joined the poor in their deprivation of good health care. Americans4. 2 million were without Health Insurance, 17 of the population. The Affordable Care act reduced int to just below 27 million 2016. Broadening the ability of americans to access Quality Health care has not been easy because unlike many of the countries throughout the world, the government of the United States long remained distant from caring for individuals not in the uniform of the United States military. There were exceptions, such as the care of seamen and marine in hospitals established in 1798 legislation signed by president john adams, or the medical attention rendered to civilians by the Freedmens Bureau after the civil war. However, for the most part, congress has resisted initiative to involve the government and Offering Health care or insurance to any but the military. Few americans realize that it was the process the vociferous Theodore Roosevelt who was the first to unsuccessfully but passionately advocate for national Health Insurance in the first decade of the 20th century. Franklin, aousin democrat and later still, harry truman, Lyndon Johnson, and bill clinton pursued a role for the federal government in providing health care to all americans. Johnsons medicare and medicaid offered some relief to vulnerable populations, but not until the Obama Administration did the federal government offered a fresh path to relieving the anxieties of those shot out of Health Insurance shut out of Health Insurance and the Health Insurance market. However, many issues remain. Where are we now . How can history help us . America,d states of the richest and most medically accomplished country in the globe has still to solve many problems. The American Population suffers from some of the highest Health Care Costs on the planets. According to 2017 estimates, we spend 3. 5 trillion every year, around 17. 9 of the gdp, and about 10,739 each year in Health Care Costs per person. But it is doubtful whether this high expenditure translates into true patient care and health care outcomes. The commonwealth fundss 2018 study of 11 countries, including australia canada, france, the swedenands, norway, switzerland and the u. K. Lastd that the u. S. Ranked for health outcomes. Equity and quality, despite having the highest per Capita Health earnings, last. The study also found that more americans die from poor care quality than the citizens of any other country involved in the study. Also, for access to primary care in the u. S. Has contributed to inadequate chronic disease prevention and management. Delayed diagnoses and safety concerns, among other issues. Much of the care accessed by americans is inadequate to their need. Prices of pharmaceuticals are sky high as compared to other countries, especially for lifesaving drugs such as insulin. The population of the country remains underinsured as of the political debates of different approaches sizzle in the prelude to the next election. Everything has a history. That is our motto at the National History center. Everything has a history. Before we can get to a better place, we need to understand how we came to this path, and where we find it so difficult to get the American Population to a better place with respect to health care, as so many other countries have done. Fortunately, we have two superb historian with us this morning who can lead us through that tangle that has been the history of health care in the United States. We need to know that past before we can intelligently navigate successfully through the rough waters of social and political debate that lay ahead. Our first speaker this morning statefessor nancy tomes, university of new york distant wish professor at Stony Brook University, author of 4 books, a generous confidence, the art of asylum giving, published in 1984, madness in america, cultural and medical perceptions of Mental Illness before 1914, a coauthored work, the gospel of life, and, women and most recently, how madison avenue and modern medicine turned patients into consumers, 2016. The gospel of germs, she won both the American Association for the history of medicines medal in the history of Science Society prize. The American Public Health Association awarded her an award for her distinguished body of scholarship in the history of public she received the very prestigious bankrupt prize for distinguished work in American History for remaking the american patient. Our second speaker this morning who teaches hoffman at Northern Illinois university where she is heinz fellow in in theaduate teaching humanities. She is the author of two books on the u. S. Health care system. Of andthe Politics Health care for some, rights and rationing in the United States. Volume a coedited patients as policy advocates. She has published many articles dealing with areas aspects of the Health Care System from the history of Emergency Rooms to the origins of copayments and adaptable. Her work has been supported by the National Endowment of humanities. Johnsonrobert wood foundation. And she has received a broad recognition in many ways. In 2015, she gave the commencement address at Loyola School of medicine in chicago. And so, it is with great firstre that i introduce the professor to come to the podium. Thank you. Thank you for that nice introduction. To focus on one unique feature of health care. That we think of health care primarily as a commodity. It should and must be delivered according to market east principles. Through our feeforservice system, providers breakdown medical care in Component Parts and charge for each product and service separately. Is each stage of care, it accepted that someone will make a profit doing so. Building a robust profit into supposedly driving the system to offer more and better care. Since the ultimate purchaser of patient,ces is the Better Health as well as profit taking involves getting people to purchase more Health Care Products and services. As a result, medical care in the United States is embedded in our Broader Consumer culture. Leading to our cult am referring custom of to patients and Health Care Consumers and doctors as health care providers. At this point, many of you are probably thinking of course. This is how modern medicine works. Doesnt everyone think this way . In fact, no. You discover that they do not market ties health care tize health care. Over the past two years, i have spent a lot of time in the netherlands. About as pragmatic and capitalist a nation as you will want to find and they are baffled why two traits of the american way of medicine. The aggressive use of marketing with advertising and the resistance to giving all citizens Health Insurance. One of the most distinctive traits of American Health care heavy reliance on sophisticated marketing and advertising. If you watch network tv, you are familiar with one such promotion. Zealand is the only other country in the world that allows this kind of advertising. Anywhere else it is thought to be an inappropriate invasion of the doctorpatient relationship. In the u. S. , even more money is spent on marketing and advertising to doctors, to influence their choice of what drugs and devices to prescribe for their patients. Companies compete fiercely to influence socalled physician preference items, which brand of pacemaker a doctor chooses. A hefty chunk of money goes to advertising hospital chains and highvolume medical procedures. Such as lasix. Our european peers look at all of the money spent on marketing and advertising designed to promote the newest and most expensive medicine, and say, no wonder you cannot ensure inshore insure everyone. Advanced biomedicine in other countries is expensive but somehow they managed to control the cost and provide almost universal access. When i visited the netherlands, their hospitals are exactly like ours. But no advertising. All citizens are covered. The dutch were not worried about their Health Insurance, it is hard to believe. And the most heartbreaking teacher of the u. S. Situation is how we spend more money per person but do not seem to reap commence or it benefits. Benefits. Urate if you are interested, we can provide links to more studies. Why do we have this system, and how do we fix it . A lot of debate in the u. S. Focuses on the role of the federal government. Does the medical marketplace work badly because the government interferes too much or too little . It is useful to turn back the clock. What was health care prior to 1965, the year the federal government got into the business of funding medical care to medicare and medicaid . Today, i will provide a brief answer. I will show the downside of our heavily marketed system, inflated prices, and lack of access, were all evident by 1960, the first year the u. S. Health care system was declared to be in crisis. That crisis led to the federal government getting involved, ostensibly to correct for market failures. It did not work out so well either as beatrix will to you more about. The key take away point is this. Policymakers who want to turn back the clock to some version of Government Free medicine need to look carefully at what the system was like before 1965, and why it did not work. In the colonial era, guild regulation of medicine did not survive the transfer to the new world. Colonialism encouraged the motto every man his own doctor and the forerunners of todays physicians faced competition from alternative healers. You could make drugs in claim they cured cancer and there was no fda to tell you no. The medical profession was given powers to regulate itself in government got basic powers to require accurate labels on drugs. More scientific medicine yielded new diagnostic tools like the xray and new treatments, such as aseptic surgery. Regular doctors, the ancestors of todays biomedicine, provided services to their patient. The hospital became known as the doctors workshop and the surgical amphitheater where germfree, pain free surgery could now be performed. As the medical profession gained respect, it got more control over licensing, making it harder for alternative healers to compete. This new medicine required more education and technology. So it cost more. Using a feeforservice system, doctors began to pass costs onto the patient. There was no thirdparty system. The doctor gave you a bill and you paid it. As beatrix will explain, alternatives to feeforservice medicine were proposed and defeated over and over in the 20th century. Medical practice remained highly competitive and to do well, doctors had to start wearing two hats. Professional as well as modern businessmen. They sought to attract patients who could pay and started moving out of low income neighborhoods. They began to specialize, which allowed charging higher fees and the cost of medical care rose so much that after world war i, by 1926, patients were complaining about the high cost of keeping alive. The soaring cost of hospital care concerned people, setting the stage for a new product designed to provide security against health catastrophe, the private insurance policy. Franklin,ith benjamin americans have loved the concept of private insurance to hedge against bad luck and during the great depression, the insurance habit expanded to include hospital care financed through blue cross blue shield, a nonprofit plan that allowed people to save toward future hospital bills and the idea proved so popular, that by 1967, most americans had insurance through their employer. This was set up on a feeforservice basis. Hospitals are doctor hoss hospitals and doctors said, here is what i charge and insurers paid the charge without question. After world war ii and the developed nation peers, began to turn to more government involvement and regulation of Health Care Costs and delivery, what we call socialized medicine. The United States doubled down on privatized system and in the early 1950s, the Congress Said no to national Health Insurance coverage. Yes to more money to build hospitals and fund medical research through the nih. This funding enabled scientists to innovate, hospitals to provide more care and create a Health Care System the u. S. Could be proud of. During the cold war, democrats and republicans bought into the privatized approach. But there were flaws in this Free Enterprise approach that approach. In a consumer driven you dont need an advanced degree in economics to understand. In a consumer driven economy, Consumer Choice is supposed to drive competition that holds down prices and rewards excellence but the mechanism that allows consumer leverage in the marketplace do not work well in health care. Medicine embodies a fundamentally asymmetrical relationship. The doctors knows more than you do and has special powers to direct your care. When it comes to the most effective treatment, the expensive ones who could really save your life, the doctors have to order them for you. I cannot walk into a hospital and say, hook me up to an iv. Professional ethics are supposed to prevent the doctors businessman from overruling the doctor as a professional. And yet the way the American Health care was market ties to made ethics harder and harder to enforce. Between 1945 in 1965, the dynamics created a set of problem we still face. The privatized insurance system, incentivized providers to shift more care to the hospital, the most expensive venue. Doctors and hospitals charged higher prices, assuming patients had insurance to cover the cost. As pharmaceutical companies and device makers competed to offer doctors new products and services, planned obsolescence became a byword in medicine and while encouraging innovation and hightech care, the system set up an inflationary spiral in cost. Generalists who saw their patient saw incomes plummet and specialists did not. This led to the overuse of surgery and Prescription Drugs and elderly and low income people lacked Health Insurance. By 1960, politicians and journalists began to use the word crisis to describe the health care scene. It was to correct market failures, specifically the care of the elderly and low income, the federal government got into the business of health care in 1965. Support for these programs, lyndon b. Johnson agreed to set it up with all the same built in triggers incentive for over specialization, more expensive care and what the market will bear approach to pricing, we are seeing inflationary spiral again today. These are the problems we have been struggling to fix ever since but there are huge barriers to change, among them the powerful stakeholders who benefited from this system have not reached a form of cutting. This resistance has grown as the u. S. Has moved from an industrial to post industrial economy in the late 20th century. Health care has become a Major Economic engine in the u. S. 20 of our gdp. It has attracted Venture Capital funding because of the reliability of investor returns at high quality employment opportunities. But that also means it is rife with political minefields. But mess with any aspect of it, and you mess with somebodys body line and a law bottom line and a lobbyist is on your doorstep. This is a nightmare for consumers to negotiate. Patients trying to shop for a cheaper better care are at a tremendous disadvantage. While some inequities seem tolerable, other aspects would americans have long had a sense that in a doctors office, in a doctors office, people are more equal than anywhere else in the world. We have a set up a system where that ethos is hard to honor. Why are the alternatives so hard to envision . Hand the microphone over to my friend beatrice who will help you understand this. [applause] thank you for being here. The question i am going to look at today is why have we not as a nation been able to reach a political solution to the persistent problems that have been described of high cost and millions of uninsured people. But i would like to go back to something nancy said, about the netherlands never worrying about their Health Coverage. This idea of relief from worry or fear about what will happen to us when we need medical care is the reason Health Insurance was invented in the first place. Over 100 years ago, industrialized countries around the world began to establish a system to protect working people from the high cost of getting sick. It was exactly 100 years ago, 1919, that such a plan came close to passing in new york. This would have provided workers with medical and hospital coverage as well as partial coverage of the wages they lost when they cannot work. Supporters of the plan focused on how it would help alleviate some of the terrible fear that working people felt when they contemplated the vulnerability of sickness. They argued Health Insurance would rob poverty of one of its worst terrors. The bill was sponsored by a popular republican senator and with his help, it passed in the new York State Senate in april 1919 but when i got to the assembly, a powerful speaker refused to let it out of committee. Americans also feared the authoritarianism of germany, and the newer threat of state socialism emanating from the russian revolution. That was the end of the First Campaign for public Health Insurance in the u. S. As you know, this kind of emphasis on the dangers of socialism and the unamerican nature of other countries Health Systems continued to be heard for the next hundred years. There is another way each defeat of universal proposals would make it even harder to succeed the next time around, and that is the way they ended up changing the Health Care System itself. The first fight over public, nonprofit Health Insurance led to the idea and growth of private forprofit Health Insurance. The biggest opponent of the legislation in 1919 were employers who did not want to pay a share of the cost and doctors who were worried they would lose their independence, and also Insurance Companies. Commercial insurers had never offered Health Coverage before. It was seen as too risky. They fought the new york proposal because it included Life Insurance benefits that would have been in direct competition with their business. In working to defeat the legislation, the insurance a bit industry became aware of a new potential market for their product. Here is what one insurance executive said in 1917. Health insurance is engaging interest of all legislators and we should ben a position to meet their socialistic ideas by offering a good brand of sickness protection that we know can be profitably written in a larger volume. Vice president of prudential agreed in favor of compulsory Health Insurance be met by such innovation. We will see this pattern again and all other campaigns for reform. Private industry creates mechanisms that will partially meet the need for security but they are designed to prevent universal programs from being passed. These private marketdriven developments were also political. Private Health Insurance did not take off until the 1930s but the birthplace was in the 1910s. In the 1920s and 1930s, the focus shifted from lost wages to the need for medical care itself and during the depression, reformers pushed franklin road roosevelt to make this part of his Social Security act. He decided against it, worried that doctors opposition would derail other new deal priorities. But ideas change during world war ii. By 1944, he was proposing a second bill of rights which included medical care as a right. After his death, truman continued with the idea and Push Congress to Pass National Health Insurance, which would have fulfilled fdrs promise by expanding Social Security to include Health Coverage. National Health Insurance was part of trumans larger Health Agenda that included federal Hospital Construction and expanded support for medical research. Unlike earlier proposals, trumans was universal and would have covered everyone. Polls show that initially, the majority of the public supported the idea of Health Insurance for all via Social Security system. But this was also the start of the cold war. This attack was familiar from three decades earlier and something new that the medical American Association ran a campaign telling the public to fear socialized medicine. This was the first pr campaign of its kind. It may have been the most successful, because after three years, public support went down to 20 and truman plan for National Insurance never made it to a vote. Again, the reaction change the Health Care System. Congress agreed to just one part the hill burton act of 1946. It was supported because it provided for construction only with no other type of federal involvement. Hill burton maintained local control so much, it preserved the right of communities in the south to use federal taxpayer funds to build segregated hospitals. Southern democrats supported the legislation, even if they oppose opposed the national Health Insurance plan. Over the next 25 years, hill burton funded a third of the hospitals built in the u. S. And brought medical care within reach of millions of people without passing universal coverage or building primary care making health care more expensive. It also created the hospital lobby and the industry became a powerful Political Force in health care debates. The growth of hospital care in the absence of universal coverage also led to the growth of private insurance to pay for the care and in the 1940s, insurance became tied to employment as firms offered Health Benefits instead of hard wages. In 1943, the irs encouraged this by making benefits tax exempt and congress made a permanent 10 years later. Just as hill burton subsidized private hospitals, federal tax policy gave Government Support to private insurance by certain employers. The jobbased system grew until three quarters of the population had coverage by 1960. Just as the Insurance Industry had , privatethe 1910s insurance served a political function by presenting what seemed like a private sector solution to the problem of health and security. Private insurance received via the workplace had some major problems. It did not cover people without jobs. It also failed to reach millions of americans in lowwage employment, the very poor, and retirees. It became clear that private insurance was not covering enough of the population to provide real freedom from fear of sickness. In backing medicare, jfk and Lyndon Johnson avoided the opposition of Insurance Companies because medicare would cover only those people that private insurance could or would not, the elderly. In one of his speeches, lbj returned to the theme of freedom from fear. With medicare, he said older citizens will no longer have to fear that illness would wipe out their savings and destroy lifelong hope of dignity and independence. Medicare did take a page from trumans book because it was built on Social Security administrative structure, a program that was familiar unpopular. It also made it harder to attack. The ama did try once more. They hired Ronald Reagan and in a speech he insisted that medicare would lead to fullblown socialism and the end of freedom in america. This time around, the ama lost. But the fear of socialized medicine and power of the medical profession, hospitals, and the Insurance Industry shaped how the Medicare Program was designed. Providers could charge whatever they wanted. The fear of provider back let backlash led to the absence of budgeting and medicare. Alongside growing costs, unrestrained medicare payments to doctors and hospitals drove a rise in Health Expenditures after 1965. Medicare did succeed in at least partly addressing the fear that sickness can devastate us financially and physically. Seniors gained a kind of Health Security no one else in the population had. Many thought that medicare would be the first step toward similar security for all americans. Instead, by essentially giving providers a blank check, and a care would make it more difficult to pass comprehensive reform in the future because after 1970, the goal to expand the number of people covered was overwhelmed by the imperative to control cost. As medical inflation in the 1970s grew, employer Health Benefits begin by the mid1980s, nearly 80 of the Elderly Population had no Health Insurance at all. There was a crisis in uninsured patients being turned away from us Emergency Rooms, transferred to other hospitals in unstable, sometimes fatal condition. Congress acted to pass the emergency medical treatment act least6, that at guaranteed one a right to access the Health Care System in the emergency room. Studies began to show what many people already knew very well, that being uninsured could lead not only to bankruptcy, but also to the ability, suffering the bility, suffering, and even death. Clinton tried to address the crisis with a plan for universal coverage but this time deregulated the insurance network. But that also failed to reach a vote. Like earlier defeats come of this led to a major structural change in the Health Care System , and this was the spread of managed care as an attempt to contain costs. In the 1990s and 2000s, many insured americans had to accept a new kind of health plan that severely narrowed their choice of doctors and hospitals, imposed expensive costsharing and sometimes, even denied them care. Pretty soon it seemed like everyone had a health care horror story from Insurance Companies refusing to pay for care for preexisting conditions, and people choosing between paying for food and paying for medication, and families event to bankruptcy after reaching care limits. The focus of the effort changed to encompass the problem of the uninsured, but sometimes the devastating experience of people with insurance. This explains why the drafters of the Affordable Care act focused partly on expanding coverage, but especially on provisions like guaranteed issue, ending exclusions for preexisting conditions, and reforming other longstanding practices of private Health Insurance. But at the same time, the aca by plans,zing these private guaranteed private insurance would continue to be the centerpiece of the u. S. Health system. The evidence so far, as well as historical experience, tells us that the affordability in private insurance is an elusive goal. Instead, in both the aca and employer coverage, we are seeing more and more plans with extremely Narrow Networks of providers, and more and more costsharing for patients reduce bothhat choice and affordability. Since more people have insurance 2010, 20 million that didnt have it before. That is a historic achievement. But that insurance does not give them full freedom from fear. And of course, to the 7 million in this country are still uninsured. Just recently, the ceo of announced that one third of the 5 billion raised on the site each year is for medical expenses. A lot has changed in 100 years. But i guess some things havent. During my research, i learned about a practice that factory workers had in the early 20th of passinge, custom the hat around the shop for the benefit of some sick worker. One woman said a collection was taken practically every week in her workplace in the aid of fellow employees facing the cost of sickness. 100 years after we began arguing about Health Reform, the Health Care System still does not protect americans from fear of poverty or bankruptcy due to getting sick. And i hope that looking back at the original purpose of Health Insurance could be useful in guiding policy decisions today. Thank you. [applause] i would like to thank both of our speakers. If you would, please pass the cards with your questions to the aisle, and we will pick them up. Ok. Lets start with this one. Since the u. S. Health care system has been based on workplace insurance, what implications does this have for this have for women, especially in the period for the entered the workforce in large numbers . Excellent question. So women were more likely to not have Health Insurance for that reason. Not being in the workforce in equal numbers to men. But there were also ways that women were discriminated against in employer Health Insurance. For example, if was very and, for any plans before the late 1970s to cover Maternity Care and childbirth because Insurance Companies thought that people shouldnt buy insurance is they thought they were going to use it, and since pregnancy was often, not always planned , a condition, that was not an insurable condition. So women were both uninsured and underinsured in great numbers. Ok, next question, ms. Tomes. You mentioned the u. S. Leads the world in cuttingedge innovation. Are countries like the netherlands able to make comparable advancements without marketbased incentives to do so . Or any other country, historically . Yes. i think one of the myths about the american way is that this is the only way to get innovation. But in fact, there is not good evidence that this is the only way to get people to innovate and come up with new approaches. There are ways the american system produces innovations that European Countries are how weted in in terms of manage medicine, because our system is so complex. Management methods are of interest to the command but i think the idea that the only way you can get progress is through our specific model is simply not borne out in terms of the history of medical innovation. Beatrix i would just add that the innovations of the u. S. Is so famous for, they were publicprivate partnerships. The funding that the federal government started to give to our research institutions, that funds the basic research that leads to more innovations in the private sector, so it has definitely been a publicprivate partnership. Alan ok. Much of current concern about u. S. Health care focuses on high drug costs. Is this a new phenomenon or does it have deeper historical roots . Not a new phenomenon, it is a particularly interesting area in terms of looking at how government involvement in the regulation of Prescription Drugs in particular helped to drive a system of Drug Development dependent on the use of patent protection in order to encourage innovation. , the system developed again in the world war 1980s, and it set up a system that incentivized innovation but protected it in a way that made for very high cost, in terms of the Prescription Drugs. So the cost of Prescription Drugs was already an issue by the late 1950s, but people were finding this rising prices are hard to bear. Coverrse, medicare didnt Prescription Drug costs until very recently, so this has been an issue for quite some time. Alan when people talk about federal involvement in health care, they usually think of medicare and medicaid, but Veterans Affairs also offers governmentfunded health care. How did it arise and what lessons can it off for us . Great question. Offer us . Very good question, because in some ways, we have had socialized medicine for veterans since at least world war ii. The v. A. Has gone up and down in terms of its ability to provide well for our servicemen and their families. In some ways, it became a poster child for fears of what the heavy hand of government bureaucracy would retard innovation, but in part, its problems were, if you set up a system and do not give it enough money, it is not going to perform well. So there are a lot of lessons to learn. Historians of the v. A. System, i can recommend their work to you. It is fascinating stuff. Alan do either of you know how the ama has responded to calls for a National Healthcare system today . Beatrix the position of the ama has been interesting. As you heard, they were very unified in opposition to universal programs up through medicare, and that was there their lastditch attempt to oppose national reform. So after the 1970s and costs started increasing and private insurance increased in the system, doctors views started to change. By the time of the clinton debate in the 1990s, physicians were much more divided than they had ever been. One of the main reasons for that is they had fought National Healthcare because they wanted to preserve their independence, their ability to Practice Medicine as they saw fit. But by the 1990s, many physicians were now practicing under the thumb of Insurance Companies. They werent independent anymore. So they began to see much more value in creating a system in which everybody would be insured and that would actually remove that barrier between doctor and patient that the Insurance Companies had become. So some provider groups in family medicine, emergency medicine, pediatrics, have come out more strongly since the 1990s in favor of a universal plan. The ama today is back to its old tricks. [laughter] when it comes to advertising. I just saw some of the new ads that are being put out against the medicare for all idea. So it seems to me that the ama is coming out against the proposals for singlepayer. But that should not lead us to make assumptions about what position is, because physicians are much more diverse now than they used to be, and their organizations are, too. Nancy i just wanted to underline that diversity is that there is no one physician position on anything and there was not in fact in the past as well. There were always doctors who were critical of that feeforservice system i described to you, and that predicted the problems that would arise with it and i would say, today, one of the major divides in physicians opinion is around the primary care physicians. Their position has eroded dramatically since world war ii. People who provide general, basic kinds of care are really at a disadvantage in the current marketplace, and they are much more interested in solutions that might shift that. You know, i talked about the shift, to specialist back to dinner list, and that is the big difference with european systems, where the control over is much tighter, you cant just go to our specialist anytime you want to. Mention labor unions, do you think the decline of labor union powers is connected to the Health Crisis . Yes. [laughter] nancy i mean, theres a long history we can get into in terms of how the organized Labor Movement helps in many ways to gain Health Insurance through the collective bargaining process. In a way, because of weaknesses in that organized Labor Movement that left out women and people of color, it kind of shot itself in the foot. But i think its revived. I talk about postindustrial economies organized around service industries. So Service Industry unions have players iand are think in terms of trying to change the insurance system. But certainly, back in the day when organized labor was seen as not equivalent, but having power like organized business or organized medicine, they had more clout than they did certainly by the 1970s. Alan they often got better rates from blue crossblue shield. They get more comprehensive, they did that, too. Alan just the size of the membership. Nancy that backfired. They became tarred with the brush of they are just for communistic, socialistic medicine. So reforms that in european capitalist countries were not seen as red, were kind of tarred with that brush of oh my goodness, you are taking us down the road to the evil empire dominance. Alan do you think the examples of European Countries are the applicable to the United States despite having much smaller populations . Nancy yes and no. Your point taken that the netherlands is the size of maryland so the kinds of problems they face are different. If you look at germany, that is a much bigger country with a larger population. I do think that the United States could learn a lot by looking at how our capitalist democratic peer nations have managed the rise of biomedicine since world war ii. It is correct that not everything will be applicable, but trying to get a sense of why their cultural preconceptions are so different, in my work, i have come to see world war ii as the fulcrum that because countries like germany and the netherlands and france or destroyed, that they had a sense of rebuilding, of solidarity that you simply dont see in the United States. Yes, we fought in world war ii, but we did not suffer the same devastation in our own land, and we did not come out of it with the same sense of having to rebuild from the bottom up. So i think there is a lot we can learn, but your question implies , it is going to be selective because in a lot of ways, are examples are not comparable. Beatrix can i say one thing . So, the systems that nancy is talking about in europe are also very diverse. We can look at different models, but there is one thing they all have in common and i think can apply anywhere regardless of population. Some are singlepayer, some are multipayer, some are socialized medicine, some have a role for private insurance, but they all have in common that everyone is covered. Every resident in the country is covered, and that leads to a pooling of risk, which helps bring down costs. And the other thing that they have in common, is that almost every provider is in the system. All the patients are in the same system and all the providers are in the same system, which leads to choice of provider. So those are lessons that can be applied to a country of any population, i think. Alan certainly, our legacy of world war ii was the fact that many wounded veterans got excellent medical care and they wanted that for themselves and your families no matter what it would take to do that. It was the First Experience americans had en masse of Excellent Health care. Nancy and that was a source of support for the trumantype plans, it just didnt succeed. Beaches, there was also a socialist system during world war ii briefly. For Maternity Care for soldiers wives, emergency maternity infant care act. That was only temporary. Is near and dear to my heart. How do you think historical scholarship can be a useful tool inform and give decisions to inform and help with the decisionmaking by policymakers . [laughter] between scope i think we have we have to look at history to have a conversation about what is happening now. A lot of the rhetoric that was year around Health Reform debates today is not really based in accurate descriptions of the u. S. Health care system or foreign Health Care Systems. We have to understand what are the definitions, what do we mean when we say universal health care, singlepayer, things like that. How do Foreign Countries actually do what they do . I think history, if i can brag about our profession, does a good job of writing accuracy in debates, so lets hope for that. Alan history always helps. Nancy it does. Alan so, if the key is performing private insurance, how can we go about doing that . [laughter] alan we saved the toughest for last. [laughter] nancy well, the question of how you change a system when you have such a powerful economic investment, and how many people work in the private Insurance Industry, if we went, you know, tomorrow, to medicare for all as a singlepayer government run system, how many people would be out of a job . One of the arguments for the system that i described was the highpaying employment that had produced in all the people that delivered the health care, as you probably know, are administrative costs for how we deliver health care are the highest in the universe, some of the. ,e invest less in the universe probably. We invest a huge part of our health care dollar in that management. We see it as ideologically superior because it is private , but we also like the economic benefit. Changing that is really going to brokering oformous economic interests, so that the private Insurance Industry could accept the change. It is one reason i personally more i think a stabilized plan is likely to work because they are not going to go away like that. Maybe you want to make a beatrix if we Want Health Care to be more affordable, it is difficult to see a role for private insurance as it now exists. The system besides ours that include a role for Insurance Companies, most of them are actually nonprofit. They are private, but they are nonprofit. Profit motive the will obviously be a major way of reducing costs, it will reduce administrative costs and overhead. So i think i am more leaning towards thinking that private insurance, it will be very hard to find a solution through that entity. Especially because they currently have too much say in our politics, and they may be a stakeholder, but the main stakeholder in the health care of thiss the people country who need health care, and that is basically everybody. So i think they should have less private insurance should certainly have less of a say in how we develop our system. Nancy one other characteristic of our european peers is they tolerate a much higher level of government regulation, of provider behavior, of prices, who gets what care. And until we can accept that principle, that government needs to regulate, and i mean hard regulation, these problems are impossible. And we are clearly not to that place. Alan change of consciousness. Nancy yes. Alan time for one or two more. How have states relationships with the Health Care System evolved over time . Thats a question about state initiatives. Nancy great question. Do you want to . Beatrix the Health Insurance debate began at the state level from the progressive era. It was almost entirely state proposed, because National Insurance was seen as something that shouldnt happen at the federal level. The role of the states was of course, preserved in medicaid. I know there is a lot of hope for state experimentation that could help improve the Health Care System, but i think the reality historically is that one evolved into a state responsibility, it really embeds a lot of inequity in the system because theres so much differential between states in terms of medicare benefits, in terms of who they cover. So, the states certainly have a role to play, but they have also had a big role to play in preserving inequity in our system. Nancy on a more optimistic note , i think because of our federal layer cake system, there is potential for states to try out different funding schemes and possibly show that a move toward ceeo more europeanstyle model, might be possible. If you can make it work in massachusetts, if you can make it work in washington state, and that could possibly influence federal policy. That is an optimistic view. Alan last question. What, and themes have the ozark throughout the history of health care regarding both what seems to be problematic, and creates question. What creates progress . That is a great question. Vitreous go the problems beatrix that one is easy. The problems are easy. That is mostly what we talked about. The thing that keeps coming up over and over again is the distortion in the debates so that the debates that take place politically are not they distort the reality of our Health Care Systems so we have not had an honest discussion of how we actually deliver health care in this country, and that is what is necessary in order to change it. Nancy i would say that one of the lessons i have learned is the dangers of hyper individualism and the importance senselth care of having a this is quoting a recent commentator that america has lost its sense that we are all in this together, and that we do not have a sense of solidarity. This is what my dutch friends are, like, what is wrong with you people . T is that hyper individualism we think it is so important to individualize everything and also to have competition. The worst thing you can do for the american character would be to relieve people of the fear that their health care is going to be covered. That you would all start being lazy, unmotivated people. That is a lot of the ideology that drives this, the fear of welfare mentality taking over. Usually, your fear of welfare is it is not going to be your family, it will be the family across the street or across the city whose skin is a different color or perhaps didnt grow up in the United States. So individualism versus solidarity. Are we all in this together . Big question that bears discussion. And i think along those lines, one example of success, something that has worked, it is not a topdown process. Medicare is often attributed to the power of Lyndon Johnson and his negotiating prowess. He is amazing. By he was actually flushed the civil rights movement, and by Senior Citizens organizations to take the stand he did on medicare. So again, it goes back to the people organizing. They are the ones who pushed the politicians to make change in. He face of all the obstacles alan some tough questions, excellent answers. Thank you all for coming this morning. Nancy thank you, great questions. [applause] in please thank me please join me in thanking our guests. [applause] [indistinct conversations] announcer this is American History tv on cspan3, where each weekend, we feature 48 hours of programs exploring our nations best. Nations past. Announcer founded in 16, tombstone was the first English Settlement in north america. Several years later in the summer of 1619 was the first meeting of the General Assembly which established representative government. This weekend in American History tv a threepart harmony in jamestown, commemorating the 400th anniversary of the first assembly. Here is a preview. It is my belief that the citizens of virginia have most certainly welcomed this method of establishing laws grounded in english, law and elliptical institutions including this newly formed assembly that will certainly continue to attend to the affairs of virginia for some time to come. Today, as we mark the first meeting of that General Assembly that took place on the same day some few years passed would say that as near as may be , we have brought virginia to the laudable form of just government we all knew in good. Fellow friends and counselor, a man who i appointed speaker in the first meeting of our General Assembly, for his elections of that gathering for his recollections of that gathering. Governor yardley. I remember one you and i along with a few appointed counselors and about 20 elected burgesses began reading together on this very date, july the 30th, during the torrid and 1619. Summer of our first legislative session was held in the choir of the church here in jamestown, as it was the most convenient place we could find to sit. Tro, the governor appointed me from his counsel to serve as a speaker for the whole assembly, not because of my kinship to his wife, lady , but rather, i was the only member of the assembly who had served as an elected lawmaker in the house of commons. There upon my experience to organize our new assembly and reduce all the matters pending before it into a ready method, to the greater ease of the members. Watch the entire three first sermon commemorating the 400th anniversary of the first virginia General Assembly starting monday at 8 p. M. Eastern. Youre watching American History tv. American history tv products are now available at the new cspan online store. To seeease ken starr. Org what is new for American History tv tuned in and check out all the cspan products. Next on lectures in history, Stony Brook University professor paul colton teaches a class about Abraham Lincoln and native americans. He talked about the dakota wars in minnesota which resulted in 38 executions, the removal of the navajo, and good afternoon, everyone. Thank you. Today, the lecture will be on Abraham Lincoln. Many of you dont think of Abraham Lincoln in contact of American Indian or indigenous history. Thats what we are going to talk about today