Events are strictly nonpartisan, they are not intended to offer any kind of policy recommendations or agendas. They are simply meant to give greater insight into how we got to where we are, which we believe helps us to understand how we can solve problems. So a few thanks, and then i will turn it over to alan. First of all, the Mellon Foundation funds this program. We are very grateful to them. Secondly, the room has been booked for us by congressman jerry connollys office, and we are grateful to them. Finally, i want to thank my reiger,t director, jeff who is at the table outside but will be coming in shortly. Now i will turn it over to professor alan kraut from the american university, who will moderate the event. Before i do, let me say, most of you will find these index cards on your seat. The intent of these is that as the discussion proceeds, if you have questions, write them on these cards. We will collect them after formal remarks and use them to initiate the discussion. Think about that as they are giving their remarks. Alan . Alan thank you, dane. Good morning. In 1941, the influential publisher henry louis declared 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 sciences, in discovery and research and vaccine development, and surgical innovation, the United States was and remains dominant, much as france, england, and germany had been in the medical vanguard in an earlier era. Medical heroes abounded. The conquerors of polio, dr. Jonas salk. A heart surgeon performed the first coronary bypass operation in 1964. Thomas starzl, sometimes called the father of modern transplantation, performed the first human liver transplant in 1963. And then there was the miraculous benefits of the human genome project at the National Institutes of health. The problem is that the wondrous results produced by american researchers, surgeons, epidemic fighters was not always accessible by the American Population broadly and equitably. Too often, health care in the United States was among the privileges enjoyed by the wealthy or postwar americans who had access to Good Health Insurance policies, many purchased in the workplace. After the birth of the blues in the midcentury, and of course, i mean blue cross and blue shield, labor unions and private employers negotiated excellent 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. By 2008, 44. 2 million americans were without Health Insurance, 17 of the population. The Affordable Care act reduced that to just below 27 million in 2016. Broadening the ability of americans to access Quality Health care has not been easy because unlike many other 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 in the marine hospitals established in 1798 legislation signed by president john adams, or the medical attention rendered to civilians by the shortlived Freedmens Bureau after the civil war. However, for the most part, congress has resisted initiative s to involve the government and government in Offering Health care or insurance to any but the military. Few americans realize that it was the vociferous republican progressive Theodore Roosevelt who was the first to unsuccessfully but passionately advocate for national Health Insurance in the first decade of the 20th century. Later, his cousin franklin, a 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 offer a fresh path to relieving the anxieties of those shut out of Health Insurance and the Health Insurance market. However, many issues remain. So where are we now . How can history help us . The United States of america, the richest and most medically accomplished country in the on the globe, has still to solve many problems. The American Population suffers from some of the highest Health Care Costs on the planet. 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 improved patient care and health care outcomes. The commonwealth funds 2018 study of 11 countries, including australia, canada, france, the netherlands, germany, norway, sweden, switzerland, and the u. K. , found that the u. S. Ranked last 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, poor 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 as the political debates of different approaches sizzle in the prelude to the next election. Everything has a history. Thats our motto at the National History center. Everything has a history. And before we can get to a better place, we need to understand how we came to this and why 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 historians 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 is professor nancy tomes, state cuny State University of new york distinguished professor at stony brook university. She is the author of four books. A generous confidence, the art of aside them keeping, published in 1984. Madness in america, cultural and medical perceptions of Mental Illness before 1914. A coauthored work. The gospel of germs, men, women and life. And most recently, how madison avenue and modern medicine turned patients into consumers, 2016. For the gospel of germs, professor tomes won both the American Association for the history of medicines medal in and the history of Science Society prize. The American PublicHealth Association awarded her an award for her distinguished body of scholarship in the history of public health, and most recently in 2017, she received the very prestigious bancroft prize for distinguished work in American History, for remaking the american patient. Our second speaker this morning Beatrix Hoffman who teaches a Northern Illinois university where she is a heinz teaching undergraduate in humanities. She is the author of two books on the Health Care System, the wages of sickness the politics of Health Insurance in progressive america, 2000 one, and health care for some, rights in the United States. As well as a coedited volume. Ith professor tomes she published many articles dealing with aspects of the Healthcare System from the history of Emergency Rooms to the origins of copayments and deductibles. Her work has been supported by fornational endowment humanities, the Robert Wood Johnson foundation and she received recognition in many ways. She gave the commencement address at loyola Scripps School of medicine in chicago. It is with great pleasure that i introduce first professor tomes. Nancy . Thank you for that nice introduction. My task is to talk about a unique feature of u. S. Health care, that we think of health care primarily as a commodity, a set of products and services that should and must be delivered according to market based principles. Feeforservice system, providers breakdown medical care and the Component Parts and charge for each product and service separately. At each stage of care, it is accepted and encouraged that someone will make a profit doing so. Building a robust profit incentive into care supposedly drives the system to offer more and better care. Since the ultimate purchaser of these services is the patient, Better Health as well as profit taking involves getting people to buy more Health Care Products and services. As a result, medical care in the United States is embedded in our Broader Consumer culture, our custom of referring to patients as Health Care Consumers and doctors as health care providers. Why this point, some of you are likely thinking, of course. That is how modern medicine works. Doesnt everyone think that way . In fact, no. Advancedte other capitalist democracies and you discover they do not market ties health care to the extent the u. S. Does, nor do they refer to patients as Health Care Consumers. I get invited to speak abroad precisely because people in these other countries are curious about the consumeriffic care,of u. S. Health chiefly to find out how to avoid it. Upper the past two years, i spent a lot of time in the capitalist and pragmatic a nation as you will ever want to find. They are baffled by two particular traits of the american way of medicine. The aggressive use of marketing and advertising, and the resistance to giving all citizens help insurance. One of the most distinctive traits of American Health care is its heavy reliance on sophisticated marketing and advertising. If you watch network tv, you are familiar with one such promotion advertisingnsumer of Prescription Drugs. New zealand is the only other country in the world that allows this kind of advertising. Everywhere 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 prescribed for patients. Companies compete fiercely to influence socalled physician preference items, which brand of death what brand of pacemaker a doctor chooses. A hefty chunk of money goes to advertising hospital chains and highvolume medical procedures. Our european peers look at all of the money spent on marketing and advertising designed to promote the most new and expensive medicine, and say, no of course your Health Care Costs more. It is no wonder you cant insure anyone. Advanced biomedicine in other countries is expensive but somehow our capitalist peers managed to control the cost and provide almost universal access. When i visited the netherlands, their hospitals look exactly like ours, modern, uptodate, high quality but with no advertising. All citizens are covered. My dutch friends are not worried about their health care and Health Insurance. It is hard to believe. Most heartbreaking feature of the u. S. Situation is how we spend more money per person, but do not seem to reap the commence or it benefits. Commensurate benefits. 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 contemporary policy 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 . As you ponder those questions, 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 through medicare for seniors and medicaid for low income americans . Today, i will provide a brief answer. I will show the downside of our heavily marketed system, inflationary prices, overuse of specialization, fragmentation of care and lack of access were evident by 1960, the first year the u. S. Healthcare 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. 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. Why did the u. S. Go the route of such a heavily marketized Health Care System . It is a long story. In the colonial era, guild regulation of medicine did not survive the transfer to the new world. Settler colonialism encouraged the motto, every man his own doctors weregular the forerunners of todays physicians, they faced enormous competition from alternative healers. Call yourself a doctor in the medical association couldnt do anything about it. Faced competition from alternative healers. You could make drugs in a barrel and claimed they were a cure for cancer, and no fda was there to tell you no. There was concern that snake oil elixirs were hurting the american people. The medical profession was given powers to regulate itself and government got basic powers to require accurate labels on drugs. One of the reason to the end of medical freedom is the rise of more scientific medicine that yielded new diagnostic tools like the xray and new treatments, such as aseptic surgery. Regular doctors, the ancestors of todays biomedicine, provided more effective goods and services to offer their patients. The icon of this new medicine was the hospital, which became known as the dr. s workshop. In particular the surgical amphitheater, where germfree, pain free surgery could now be performed. As the medical profession gained respect, it got more control over medical education and 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 be medical had to start wearing two hats, the medical professional and the 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. Starting with ben franklin, 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 finance through blue cross blue shield, a doctorrun nonprofit plan that allowed people to save toward future hospital bills. And the idea proved so popular, that by 1967, most americans had some kind of hospitalization insurance, mostly through their employer. This was insurance set up on a feeforservice basis. Hospitals and doctors said, here is what i charge, and that insurers paid the charge without question. After world war ii, as its developed nation peers began to turn to more government regulation of Health Care Costs and delivery, what we call socialized medicine, the United States doubled down on its privatized system, and in the early 1950s, the u. S. Congress said no to national coverage. Lots of taxpayer money to build more hospitals and fund medical research through the nih. This funding enabled scientists to innovate, hospitals to provide more care and create a H