Currently, there are potent forces taking decision making away from those who provide medical care and transferring it to third parties who are paying the bills.
History clearly records how we have reached this stage and it is time to heed the old adage, “Don’t ignore the past or you are bound to repeat it.”
Any realistic analysis of the situation leads inevitably to the conclusion that most problems facing the medical profession today carry a “Made in Washington” label. Despite the obvious political implication, it is not only unfair, but also false to ascribe malevolent intentions to many of its authors.
It was the ability to control infections, with the emergence of sulfas in the 1930s and penicillin in the early 1940s, that recorded, for the first time in history during World War II, that the implements of war killed more combatants than did infections. Simultaneously, those pharmaceutical advances, almost like materializing from Aladdin’s lamp, gave physicians new tools, and modern scientific medicine was under way. These developments also introduced a half century of government promises to provide all citizens with the medical care benefits which were rapidly evolving.
It was during the war years with wage and price controls that government waived taxes on employer-provided health insurance. Because shortly thereafter, they also declared such bounties to employees to be tax free, the seeds were planted for the later development of unforeseen problems. With wages frozen, labor leaders pushed for the expansion of medical care benefits, in lieu of wages, often to the point of first dollar coverage. This totally protected workers from any financial responsibility for medical care sought and requested for themselves and their families. Thus, the stage was set for often unlimited demands because someone else was paying their bills.
In 1945, the Hill-Burton Act was passed to reach the goal of providing available hospitals in rural, as well as urban communities. Over the next 25 years, $4 billion of federal grants to some 4,000 hospitals were supplemented by $1.9 billion in loans to 300 facilities. No nation in history has provided such access to most of its citizens.
As medical capabilities continued to advance with new drugs and new technologies, some political leaders, urged by powerful labor leaders, began campaigns to establish a government system of socialized medicine for all citizens.
These heavily financed campaigns during the 1940s, the 1950s, and the early 1960s, up to and through the presidency of John F. Kennedy were repeatedly defeated by a Congress dominated by powerful leaders of the Democratic Party like Wilbur Mills of Arkansas, Richard Russell of Georgia, Robert Kerr of Oklahoma, and Russell Long of Louisiana. Basic to their opposition was the firm conviction government aid should be limited to those in need rather than via a giant federal bureaucracy to take care of everybody.
It was the assassination of President Kennedy that led to the ascendancy of Lyndon Johnson. One of his first declarations was that there was a shortage of at least 50,000 doctors in this country. Congress promptly mandated the expansion of medical schools and the number of graduates doubled during the next 10 years. It is interesting historically that it was Joseph Califano, then in the Department of Health, Education and Welfare (HEW) who wrote Johnson’s speech projecting the necessity of growth. It was the same Joseph Califano, later as Secretary of Health and Human Services (HHS) during the Carter administration, who appeared before the Association of American Medical Colleges during a meeting in New Orleans with the remonstrance they were turning out too many doctors and that they better stop.
Having completed Kennedy’s unexpired term, Lyndon Johnson ran to be elected on his own. Among his strongest supporters and major sources for campaign funds was Walter Reuther, the head of the AFL-CIO great labor federation. Unable to obtain socialized medicine for the entire population, Reuther strongly supported a program to provide medical care for all senior citizens, rich or poor. His reasoning was that once the principle of using tax dollars from younger workers to care for all elderly citizens was established, it would be easy to stimulate working Americans to demand coverage for themselves, because they were the people paying the bills.
Once Medicare was signed into law, President Johnson forced insurance companies to stop insuring the 7.7 million elderly who had been buying and paying for their own insurance. My parents were among those who were then forced into Medicare, the 16 million, rich and poor alike, to have most of their bills paid by younger workers, even though none of them had contributed anything toward the costs.
Not long after implementation of the new Medicare legislation, Walter Reuther stood before the American Public Health Association in November 1968 at Detroit proclaiming a health care crisis in America, blaming physicians for escalating costs. He demanded complete federal financing of health care for all Americans and soon after established the National Council of Senior Citizens to promote that goal. This organization continues today, reportedly with 96% of its financing with tax dollars. (Parenthetically: I debated Walter Reuther on CBS-TV nationwide and later met with him at this headquarters in Solidarity House on Jefferson Avenue, Detroit, Michigan. Walter Reuther died in a plane crash in 1970.)
In responding to medical professionals’ criticisms, Lyndon Johnson repeated the statements of Medicare proponents by saying, “All we want to do is pay the bill.” To reassure doctors and their patients, they introduced two sections into the Social Security Act.
The first promised no interference between a doctor and his patient or the manner in which care was delivered.
The second promised that everyone would be able to choose his or her own doctor.
This legislation has never been repealed — it is just ignored.
There is no denying that Medicare for the elderly and employer-provided insurance have made it possible for millions of Americans of all ages, some previously uninsured, to enjoy medical care contributing to longer, healthier, and happier lives.
However, like every other segment of Lyndon Johnson’s Great Society, government largess in health care has become an opportunity for money-grabbing entrepreneurs and for bureaucratically-engineered waste, fraud, and abuse. Everything the medical community feared and warned against has come true — the constantly expanding bureaucracy, spewing out rules and regulations, codes hampering the care of patients and gross inefficiency at every level, together with spiraling costs; meanwhile prime blame is placed at the door of medicine itself. A recent entrant in this maelstrom has been managed care, a hydra-headed entity with both meritorious intentions and pestilential components in the details.
Government promises have exceeded its ability to pay and now Medicare faces bankruptcy. Once again, medical care is forced into the political arena where solutions offered rarely include input from those who deal with real medical problems everyday.
The largest single problem facing American medicine today is the actions of government and government encouraged business to place arbitrary limits on funds provided for medical and health care in this country. It is the wrong way to deal with the complex problems of rising health care costs.
History justifies the claim that most of today’s problems in medical care had their seeds sown in Washington. Many were planted with good intentions, their proponents unaware of their potential for unwanted and unforeseen serious problems. It is these problems for which solutions are sought in the same venue from which they originated — Washington.
Too many physicians remain aloof from the political process. Substantial numbers are needed to awake to the realization that only politics and politicians can change laws and redirect medical care in the proper direction.
There are many intelligent, capable, and honest members of both political parties who want to do what is both right and just. Only political action and financial support for those of similar qualifications who seek office will ultimately accomplish a veto-proof Congress should a chameleon-like politician continue to occupy the White House.
Dr. Annis is a past president of the American Medical Association and World Medical Association, and author of the book, Code Blue--Health Care in Crisis (Regnery Gateway, Inc., 1993). His address is 9999 Northeast Second Avenue, Miami Shores, FL 33138.
Originally published in the Medical Sentinel 1996;1(1):36-38. Copyright©1996 Association of American Physicians and Surgeons (AAPS)