Published by EH.Net (August 2013)
Beatrix Hoffman, Health Care for Some: Rights and Rationing in the United States since 1930. Chicago: University of Chicago Press, 2012. xxxv + 319 pp. $30 (hardcover), ISBN: 978-0-226-34803-2.

Reviewed for EH.Net by Edward Berkowitz, Department of History, George Washington University.

This monograph provides a bill of particulars of the ways that health care in the United States gets restricted in one manner or another, causing the health care system to fall short of providing health care upon demand and becoming a basic right of citizenship. We have a highly fragmented system of health care delivery and finance that leaves many people without health insurance and hence the ability to pay for adequate care. I doubt that comes as a surprise to anyone. Indeed, chronicling the inadequacies of American health care has become something of an academic cottage industry. Of late historians have made regular contributions to this literature as, for example, relatively recent books by Alan Derickson (Health Security for All: Dreams of Universal Health Care in America, 2005) and Philip Funigiello (Chronic Politics: Health Care Security from FDR to George W. Bush, 2005) illustrate. Derickson is quite insightful about the structure of the health care system, and Funigiello does an excellent job chronicling the health insurance as a political issue from Franklin Roosevelt to the most recent Bush. Political scientists and sociologists, such as Jill Quadagno, Jacob Hacker, Paul Starr, and Theda Skocpol, have also done their part to explain the absence of national health insurance in the United States.

The size of this literature might cause one to wonder if there is anything left to say. Despite the imposing nature of the secondary literature, Beatrix Hoffman has managed to write an original book on the history of rights and rationing in the U.S. health care system since 1930. She has not only mastered the secondary literature but performed an impressive amount of research in primary source collections that are not major stops along the historian?s archival tour. These include the Alabama State Archives, various manuscript collections housed by the American Hospital Association, and the archives of the Rush-Presbyterian-St. Luke?s Hospital in Chicago. Use of these seldom seen records allows her to tell the story of American health care from the ground level of the local hospital or the doctor?s examining room, a social history approach quite different from the one taken by, say, Funigiello whose book focuses on policy history and events in Washington. Hoffman includes original material related to the efforts of civil rights activists, leaders of the Latino community, and the women?s movement to affect the content and delivery of health care.

This is a subject, though, in which social history from the bottom up only takes one so far. That local hospital in Chicago needs to pay meticulous attention to the reimbursement rules of Medicare and the Illinois state Medicaid program. Indeed, every hospital employs people who do nothing but stare at computers and try to match their current patient load with available sources of payment. One cannot, therefore, easily evade the consequences of policy decisions made in Washington and the state capitals in telling the history of U.S. health care. In Hoffman?s case, she presents masterful sketches of such programs as the Hill-Burton hospital construction program (1946), the Emergency Infant and Maternal Care program (1943), and the State Children?s Health Insurance Program (1998). Her book has the additional merit of bringing the story all the way to President Obama?s 2010 Patient Protection and Affordable Care Act.

For all of the richness and diversity of her narrative, she comes to a similar conclusion as previous scholars who write on this topic. In a typical passage, for example, she writes that the Obama health care reform ?is yet another chapter in the history of how the United States has expanded access to health coverage via subsidies to private entities. The two previous major national reforms, Hill-Burton and Medicare, both channeled significant federal funds to private hospitals and providers? (p. 218).

Never, it seems, has the United States made a whole-hearted commitment to universal health care. Medicare, a brave new advance, followed the principles of private insurance and left seniors with large hospital and doctors? bills. Even if we judge the program a relative success, it still covered only the elderly, the disabled, and, although Hoffman does not mention it, people with end stage renal disease. Medicaid was run by the states in a highly disparate manner and involved a means test that excluded many needy people from coverage, if they were not already categorically excluded because, for example, they were able-bodied males. The Hill-Burton program provided funds for hospital construction but vested power at the state and local level, with the result that the law specifically allowed southern states to maintain segregated hospitals that were partially built at federal expense. Hence, race in the hospital construction program, like age in the Medicare program, proved a barrier to the receipt of medical care. The United States also constructed an elaborate system of private health insurance, which by the 1950s Americans regarded as ?desirable, although many were unable to obtain it because of age, income, job status, or other factors? (pp. 97-98). Those who got it still faced high deductibles and other barriers that kept them from receiving all of the health care they sought.

The reader finishes Hoffman?s book with the sense that the only way to understand the seemingly irrational U.S. health care system is through history. It only makes sense if you follow the development of the system step by incremental step. It comes as no surprise, therefore, that President Obama chose incremental expansions of Medicare and Medicaid and private health insurance over creating a fundamentally new system of state run and financed health care, and even at that he faced all sorts of political difficulties from the representatives of key stake holders in the current system.

As I read the book, I got the sense that health care had become the new welfare. Welfare was once viewed as an intractable issue that involved the grossly unfair distribution of money ? a desirable commodity ? through a system that made anachronistic assumptions about those worthy of receiving that money. Health care, also a desirable commodity, gets distributed through an inefficient system that rewards the rich over the poor and the elderly over people of working age. It too has become an intractable issue. The difference between the two is that the welfare issue reached some sort of settlement in 1996, whatever one might think about the contents of the welfare reform that was passed during the Clinton era. Health insurance as an issue does not appear close to a settlement either of a liberal or conservative nature. Or maybe the Obama health care reform is the best we can do.

We blunder on, carrying heavy baggage from the past, even as the system incorporates the latest scientific and technological advances. In the hospitals, technicians who operate the latest scanning equipment work a few doors down from people, recently arrived in this country, who empty bed pans and sweep the floors. Doctors engage in a game of wits with managers in health insurance companies so that their patients can receive what the doctors regard as necessary care. Race, region, job category, income and disease category all remain relevant to the question of who receives what type of health care. Hoffman?s book probes these various categories with skill.

As one might expect with such a complicated subject, she does not get everything right. I found some of her narratives about developments in Washington, as opposed to the grass roots, a little confusing. Consider, for example, this passage about the creation of Medicare in 1965: ?But the doctors were outmaneuvered by LBJ and his new ally, powerful Ways and Means Chairman Wilbur Mills. Following pressure from the President to support his bill, Mills dramatically expanded the Medicare proposal by adding two new programs: a voluntary system to cover doctors? bills ? virtually identical to the AMA?s alternative plan ? that would become known as Medicare Part B; and Medicaid, health insurance for public assistance recipients?? (p. 123).

As I read these same events, it is not clear who outmaneuvered whom. Mills achieved his objectives and protected his interests. Nor is all that clear that it was pressure from LBJ that motivated Mills? actions so much as the effects of the election of 1964 and the expansion of the Ways and Means Committee in 1965 to include more members favorable to Medicare. In addition, Medicare Part B stemmed from a proposal by Representative John Byrnes that was not in any sense ?virtually identical to the AMA?s alternative plan.? If the AMA could claim paternity for any part of the 1965 legislation, it would be for Medicaid. These are small details and possibly matters of emphasis, but they detract somewhat from the narrative.

Hoffman makes a point of stating that she is as interested in health care at the grass roots as she is in the byzantine health politics in Washington. In other words, her work provides a refreshing correction to that of people like me who are obsessively concerned with arcane events in the bureaucracy and Congressional committees. If I were to turn the tables, I would question just how much grass roots activists have been able to achieve in the health care field. There is no doubt, for example, that feminist critiques of the health care system proved influential in changing the nature of child birth as a medical event. Pregnant women, no longer sedated at the doctor?s convenience, have greater agency in this process. Fathers have also entered the obstetrical wards. Johns Hopkins, for example, features a birthing center that allows the father to bunk in with the new mother. At the same time, this development makes the already costly health care system that much more expensive and furthers the class divisions in the provision and receipt of health care. Activists in this instance have had agendas that, whatever their merits, do not exactly mesh with the goal of universal health care.

I also question some of the links that Hoffman makes between civil rights and health care. She writes, for example, that ?Civil rights activists, ?energetic elderly persons?, and organized labor provided the public pressure needed for both JFK and LBJ to act and to succeed as health reform leaders? (p. 125). This sentence implies a much more active role for the civil rights activists than my reading of the record indicates. Just as internecine battles distracted the labor movement during the passage of the Social Security Act in 1935 and limited its effectiveness in lobbying for the measure, so the leaders of the civil rights movement were preoccupied by monumental matters like the passage of the Voting Rights Act in 1965. Inevitably, they paid little attention to Medicare and, if they did, they concentrated on the desegregation of hospitals and not on the key health care financing battles. To be sure, the leading national organization of black physicians supported Medicare and the AMA opposed Medicare, but these black physicians were only one part of a relatively large number of liberal doctors whom Medicare supporters used to bolster their case. In this case, the labor unions mattered much more than did the civil rights activists or the advocates for welfare rights.

Similarly, Hoffman points to the exclusion of African Americans from hospitals in major metropolitan areas, such as Chicago, as a major deficit of the health care system. No doubt it was, but blacks were not the very large minority group they would later become in Chicago and elsewhere in the North. What happened to Jewish patients? Polish patients?? These minorities tend to get forgotten in Hoffman?s account, despite their prominence in Chicago, New York, and elsewhere. The development of Jewish and Catholic hospitals figures hardly at all in the narrative.

In other words, the concerns of the historian of health care, even one inclined toward social history, do not have to mirror all of the concerns of social history more generally. Maybe the historians in this field need to attempt a graceful synthesis of policy and social history. On the question of health care finance, Beatrix Hoffman had made an impressive start on that project, producing both social and political history of the highest order.

Edward Berkowitz has written books on Social Security, the welfare state, American health care institutions, and disability policy as well as more general histories of the 1970s and popular culture. His most recent book, co-written with Larry DeWitt, is The Other Welfare: Supplemental Security Income and U.S. Social Policy published by Cornell University Press in 2013.

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