Beginnings Count: the Technological Imperative in American Health Care
Rothman's book is an engaging, interesting, and complex one, easy to read, more difficult to evaluate. It is most obviously a collection of essays on what the author calls "decisive moments in the evolution of American public policy and public attitudes." There are six such moments, whose "tales," Rothman notes, cover "critical innovations" in the history of health insurance and medical technology. Each of the resulting six chapters takes up one of these "decisive moments." Those on health insurance deal with the origins and growth of Blue Cross, the enactment of Medicare, and the (failed) reform effort of President Bill Clinton. The technological tales deal with the origins and importance in American medical history of the iron lung, the dialysis machine, and the respirator. Each of these tales is vividly told, buttressed by documentary evidence from the period, and forcefully communicated -- with the message that these are "not case studies as such" but, rather, "intensive analyses of major turning points" in the history of the provision and financing of American medical care, and of attitudes toward it.It is precisely the claim of explanatory power for the tales that raises the most profound questions about Rothman's work. The episodes are enormously interesting on their own. Rothman has conveyed superbly how the leaders of Blue Cross justified their version of private social insurance as a barrier against "government medicine" and a benefit specially designed for the employed middle class of America. In describing the passage of the legislation establishing Medicare (and the accompanying rhetoric), Rothman captures well the ways in which the elderly were presumed to be legitimate objects of governmental protection and how the acceptability of Social Security figured in the rationale for passage in 1965. In accounting for the demise of the Clinton health care reform bill, Rothman covers the ground others have plowed, but he does so with a craftsman's eye for the compelling detail, the vivid illustration, and the example that supports the message of his tale. The same is true for the explication of each of the technological innovations -- who invented them, how they were "sold" as crucial improvements, and how each of them figured in the long-standing dispute over who was to be insured for what in American medical care.The problem this work presents, then, is one of interpretation, not readability. Taken as a collection of fascinating tales, this is a book well worth reading by any student of American medicine. Taken as an explanation of why American medical care has taken the form it has in the 20th century, this book stretches beyond its intellectual grasp. There are two central reasons for this crucial limitation. First, to narrate an episode -- however compellingly -- is not to explain a later development. Calling such narratives "lived history" does not change matters at all. What such episodes can legitimately do is suggest causal factors that might well, on separate examination of the evidence, support a causal account of the subsequent development. Part of the problem here is linguistic and stylistic. To describe the history of American medical care as an "evolution" is to suggest a dependence of one period on previous ones that is not demonstrated by the simple use of the term.Let me illustrate such a gap between claim and evidence. Rothman's description of the growth of Blue Cross from the 1930s on is, as noted, an excellent story. But he goes on to claim that it was the "decisive moment" in the "allocation of responsibility" between government and nongovernmental health insurers. Because Rothman believes that his is an explanation of American exceptionalism (the absence of universal health insurance), comparative evidence is crucial here. Canada, for example, also rejected government health insurance in the middle of the Great Depression and expanded the functional equivalent of both Blue Cross and Blue Shield in the decade after World War II. Medically similar, with a distribution of values that made North America not identical, but very close, Canada ended up with national health insurance by 1971 and the United States did not. Each country expanded the role of government in increments. Canada did so according to the type of service (insurance for hospital care in the late 1950s, for physicians' services in the late 1960s); the United States did so according to population groups (veterans in the late 1940s, the poor elderly in 1960, all the elderly under Medicare and many of the poor under Medicaid). It is intellectually questionable, to say the least, to use a common factor (Blue Cross coverage) in the explanation of later developments that differ between Canada and the United States.It would be churlish to list the many examples of the gap between description and explanation in this otherwise admirable book. The point, rather, is that a collection of essays about moments in history cannot substitute for an explanation of major features of a nation's medical care. One can explain particular episodes well, as Rothman generally does, and still not arrive at a compelling account of why the United States, unlike its counterparts among the industrial democracies, does not have universal health insurance. To do so requires both comparative political analysis and a posing of competing hypotheses against which the evidence is arrayed. Good stories cannot substitute for that.Reviewed by Theodore R. Marmor, Ph.D.Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.