Doctors and Reformers: Discussion and Debate over Health Policy, 1925-1950
Doctors and Reformers is a remarkably detailed account of the "discussion and debate" over health insurance reform during the second quarter of the 20th century. As its title implies, this book is about the major legislative remedies introduced by reformers ("professional reformers, foundation executives, philanthropists, civil servants, academics, liberal politicians, fringe medical associations, prominent individuals, labor groups, and farmers' unions") and the truculent rejoinders from the doctors (organized medicine and independent physicians) over a period of 25 years. Engel begins in the early 1920s, a period of legislative quiet following the failed lobbying efforts by the American Association for Labor Legislation for compulsory sickness insurance, and then describes the Committee on the Costs of Medical Care, a privately funded group that published the first reliable reports on the national distribution of medical expenditures; the Committee on Economic Security, appointed in 1934 by President Franklin D. Roosevelt to study and make recommendations concerning social security; the Interdepartmental Committee to Coordinate Health and Welfare Activities, created in 1935 by Roosevelt to study and make recommendations on the federal government's health-related activities; Senator Robert Wagner's failed National Health Bill of 1939 and the Wagner-Murray-Dingell bills of 1943 to 1947; and President Harry Truman's 1945 speech urging the creation of national health insurance. The years covered by the book were, as Engel puts it, the "era of Fishbein" -- so named because of Morris Fishbein, the "thuggish" long-time editor of the Journal of the American Medical Association. Despite never having held an elected leadership position in the American Medical Association (AMA), Fishbein was to the American public "virtually the face of the association" and the "embodiment of the association's beliefs." Throughout the debates over health insurance, he consistently called on Americans to reject "socialized" or "sovietized" medicine. Under his leadership, the AMA was instrumental in suppressing each serious attempt at creating a national health insurance program. In 1949, the AMA ousted Fishbein and then undertook a very costly public-relations campaign opposing national health insurance. At the point when the AMA and the medical lobby had become a "unified, undefeatable legislative foe," Engel brings his history to an end. That the AMA historically opposed government involvement in payment for medical care is hardly astonishing. More surprising is the nature of the debates, which are characterized by Engel as often vituperative, rather than merely contentious. For example, Fishbein's claim that Wagner's National Health Bill "ultimately must result in a trend toward communism and totalitarianism and away from democracy as the established form of government" highlights his tendency to use inflammatory and unhelpful language. Not all physicians were of the same mind as the AMA, however, and Engel captures this heterogeneity in the writings of rank-and-file physicians as well as those affiliated with reform-minded organizations, including John Peters of the Committee of Physicians for the Improvement of Medical Care and Ernst Boas of the Physicians' Forum. Relying heavily on the personal papers of participants, especially those of reformers Michael Davis and Isidore Falk, this history is bounded by the limits of their active lives. Quoting extensively from letters, editorials, and organizational documents, Engel is at his best when chronicling these debates in detail. In doing so, he crafts a readable, if narrowly focused, book. This book is thus a history of ideas and men (and occasionally women) rather than of social trends. Engel explains that the failure of meaningful reform of health insurance, in particular Wagner's National Health Bill and the successive Wagner-Murray-Dingell bills, was in large part attributable to the reformers' failure to understand the nature of the challenges they faced. Because they focused narrowly on the role of the AMA in opposing reform, writes Engel, they lacked insight into a fundamental characteristic of the American citizenry: "Despite the inability of millions to afford necessary medical and hospital services, Americans simply did not want national health insurance." In the face of such resistance, the reformers' efforts were "positively quixotic." Clearly recognized but purposefully given little coverage are two major social developments: the rise of Blue Cross and Blue Shield and the provision of health insurance as a fringe benefit for defense workers during World War II, both of which dampened the public's demand for national health insurance. Doctors and Reformers is thorough enough for scholars, yet engaging enough for dabblers like us. General readers will learn to what extent we are stuck in a rut, as they recognize in the debates of 1925 through 1950 the spinning of the same wheels that spin today in debates over national health insurance and the plight of the uninsured. The scholar will find in this book a thorough review of such debates but may be put off by occasional errors. (For example, in-hospital mortality rates were not in the neighborhood of 50 percent at the start of the 1900s, as is noted on page 4. And Senator Henry Cabot Lodge is listed as a Democrat on page 179 but as a Republican on page 266.) This book may hold the greatest appeal for those inspiring persons who are involved in the movement to improve health care for the benefit of all, for we must all learn from history if we are to change its course.Duncan Neuhauser, Ph.D.Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.