On the history of u. S. Iranian relations. I should stress that these events are strictly nonpartisan. They are not intended to offer any kind of policy recommendations or agendas. They are simply sort of meant to give greater insight into how we got to where we are, which we believe helps us understand how we solve problems. So, a few thanks and then ill turn it over to alan. First of all, the Mellon Foundation funds this program. Were very grateful for them. Secondly, the room has been booked for us by congressman jerry connollys office. Finally, i want to thank my assistant director, who is at the table outside and will be coming in shortly. Now, i will turn this over to the professor of american university, who will moderate the event. Most of you will find these index cards on your seats. The intent is, 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 discussion. Alright . So think about that as they are iving their remarks. Thank you, dane. Good morning. In 1941, the influential publisher 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. Medical heroes abounded. A heart surgeon performed the first coronary bypass operation in 1964. Thomas, 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. The problem is that the wondrous results produced by american researchers 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 in 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, liquor unions of private employers negotiated excellent medical plans for employees. 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 are. 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 for americans to access Quality Health care has not been easy. Because unlike many countries throughout the world, the government of the United States long remains distant from caring for individuals not in the uniform of the United States ilitary. There were exceptions, such as the care of seamen and marine in hospitals established in 1798 legislation, signed by president john adams. Or the medical attention rendered to civilians by the short lives after the civil war. However, for the most part, congress has resisted initiatives to involve the government in Offering Health care or insurance to any but the ilitary. Few americans realize it was the vociferous republican president theodore roosevelt, who was the first to successfully, but passionately, advocated for Health Insurance and the 20th century. Later, his cousin, a democrat, and still 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 has the richest country on the globe has still to solve many problems. We have 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 per person each year in Health Care Costs. But its doubtful whether this high expenditure translates into true patient care and health care outcomes. The commonwealth funds 2018 study of 11 countries, including australia canada, france, the netherlands, 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 diagnose and safety concerns, among other issues. Much of the care accessed by americans is inadequate to the need. Prices of pharmaceuticals are sky high as compared to other countries, especially for lifesaving drugs such as insulin and the population of the country remains underinsured as the political debates says unless 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 past and why, 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. Some of the 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, we must 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 Suny State University of new york distinguished professor at stony brook university. She is the author of four books, a generous confidence Thomas Story Kirkbride and the art of asylum keeping, published in 1984, madness in america cultural and medical perceptions of Mental Illness before 1914, coauthored work, the gospel of germs men, women and the microbe in american life, 1998, 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 welsh medal and the history of science societys davis prize. In 2011, the American PublicHealth Association awarded her the arthur viseltear award for her distinguished body of scholarship in the history of public health. 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 is professor beatrix hoffman, who teaches at Northern Illinois university, where she is hainds fellow in undergraduate teaching in the humanities. She is the author of two books on the u. S. Health care system the wages of sickness the politics of Health Insurance in progressive america, 2001, and health care for some rights and rationing in the United States since 1930, 2012 as well as the coedited volume, patients as policy actors, which she coedited with professor tomes. She has published many articles dealing with various aspects of the Health Care System, from the history of Emergency Rooms to the origins of copayments and deductibles. Her work has been supported by the National Endowment for the humanities, the American Council of learned societies, the Robert Wood Johnson foundation, and she has received broad recognition in many ways. In 2015, she gave the commencement address at Loyola Stritch school of medicine in chicago. And so it is with great pleasure that i introduce first professor tomes. Please come to the podium, nancy. Thank you, alan, for that nice introduction. Well, my task today is to historicize one 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 marketbased principles. Through our Fever Service system, providers break down medical care into 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 profittaking, 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, leading to our custom of referring to patients as Health Care Consumers and doctors as health care providers. By this point, some of you all are likely thinking, well, of course. That is just how modern medicine works. Doesnt everyone think that way . In fact, no. Investigate other advanced capitalist democracies and you discover they do not marketize health care to the extent that the u. S. Does, nor do they refer to patients as Health Care Consumers. Because of my work, i now get invited to speak abroad precisely because people in these other countries are curious about the consumerification of u. S. Health care, chiefly to find out how to avoid it. Over the past two years, ive spent a lot of time in the netherlands, about as pragmatic and capitalist a nation as you will ever want to find, and 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 Health 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, direct to Consumer Advertising 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 prescribe for their patients. Companies compete fiercely to influence socalled physician preference items, ppis. That is, what brand of hip prosthesis or pacemaker a doctor chooses. Finally, another hefty chunk of money now goes to advertising hospital chains and highvolume medical procedures such as lasik. Our european peers look at all of this money spent on marketing and advertising designed to promote the newest and most expensive drugs and procedures, and say, well, of course your Health Care Costs more than everyone elses, and thus its no wonder you cant insure everyone. To be sure, advanced biomedicine in other countries is honkingly expensive but somehow our capitalist peers manage to control those costs and to provide almost universal access to it. When i visit the netherlands, their hospitals look exactly like ours. Modern, uptodate, high quality, but with no advertising. All citizens are covered. My dutch friends are so on worried about their health care and Health Insurance it is hard to believe. And perhaps the most heartbreaking feature of the u. S. Situation is how we spend more money per person but do not seem to reap the benefits. The United States scored poorly on many basic indicators used by policies policy makers to measure the quality and effectiveness of health care delivery. If you are interested, we can provide links to more studies. So 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 federal 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 finally got into the business of funding medical care through medicare and medicaid . Today, i will provide a brief answer. As i will show the downside of system,ily marketed inflated prices, overuse of specialization, fragmentation of care and lack of access, were , all evident by 1960, the first year the u. S. Health care system was declared to be in crisis. In fact, it was that crisis that led to the federal government getting involved, ostensibly to correct for market failures. That did not work out so well either. 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 . Let me concentrate on the most important bits. In the colonial era, old world traditions of guild regulation of medicine did not survive the transfer to the new world. Colonialism encouraged the motto, every man his own doctor and regular doctors the , forerunners of todays physicians, faced competition from alternative healers. Doctorld call yourself a and the American Medical Association could not do anything about it. You could make drugs in a barrel and claimed they would cure cancer and there was no federal drug and ministration to tell you know. That culture began to change at the turn of the last century out quackery andthat snake oil in lectures elixirs were hurting the american people. The medical profession was given powers to regulate itself in government got basic powers to require accurate labels on drugs. One reason was 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 acquired more effective goods and services to offer their patients. The icon of this was the hospital, which became known as the dr. s workshop, and the surgical amphitheater where germfree, pain free surgery could now be performed. As the mainstream medical profession gained respect, it over medicalrol education and licensing making , it harder for alternative healers to compete. This new medicine required more education and technology. So it had to 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. 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 start wearing two hats, one as the medical professional and the other as a 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 most 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 cap it, as it was called expanded to include hospital , care finance through blue cross blue shield, a nonprofit plan that allowed people to save toward future hospital bills and the idea proved so popular, that by 1960 seven, 2 of americans had some kind of hospitalization insurance, mostly through their employers. This was set up on a feeforservice basis. Hospitals and doctors said, here is what i charge, and the insurers paid that charge without question. After world war two, as 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 Congress Said no to national coverage. Health insurance, yes to spending money to build more hospitals and fund medical research through the nih. All this funding would enable scientists to innovate, hospitals to provide more care and create a Health Care System the u. S. Could be proud of. In the midst of the cold war, democrats and republicans bought into the privatized approach. But there were flaws in this Free Enterprise approach that you do not need an advanced degree in economics to understand. In a consumer driven economy, Consumer Choice is supposed to drive competition that holds down prices and rewards excellence but the mechanism that allow consumers leverage in the marketplace do not work well in health care. Medicine embodies an asymmetrical relationship. The doctor knows more than you do and has special powers to direct your care. When it comes to the most effective treatment, the ones that could really save your life, the doctor has to order them for you. I cannot walk into a hospital and say, hook me up to an iv. Medicines professional ethics are supposed to prevent the businessmen from overruling the doctor as professional and yet the way the , American Health care was marketized made ethics harder and harder to enforce. Between 1945 in 1965, the dynamics created a set of problem we still face. The privatized insurance system, incentivized providers to shift more care to the hospital, the most expensive venue. Both doctors and hospitals charge higher prices assuming , patients had insurance to cover the cost. Not all of them did. As pharmaceutical companies and medical device makers competed to offer doctors new products and services, plans became a planned obsolete since scence became a byword in medicine and while encouraging innovation and hightech care, the system set up a spiral and cost. Generalists who saw their patient saw incomes plummet and specialists did not. Worries grew that the system promoted overuse of surgery and Prescription Drugs. Americans, groups of elderly and low income families in particular, lacked any Health Insurance at all. By 1960, politicians and journalists began to use the word crisis to describe the American Health care scene. It was to correct the market failures of this american way of medicine, specifically the care of the elderly and the low income, that the federal government finally got into the business of health care in 1965. To gain support for these programs, lyndon b. Johnson agreed to set it up as a taxpayerfunded version of the private Health Care System with , all the same built in triggers , incentives for more expensive care, and what the market will bear approach to pricing, we are worsening the inflationary spiral we deal with to this day. These are the problems we have been struggling to fix ever since but there are huge barriers to change, among them the powerful stakeholders who benefited from this system have and thus resist any form of costcutting. This resistance has grown as the u. S. Has moved from an industrial to post industrial economy. Health care has become a Major Economic engine in the u. S. About 20 of our gdp. It has attracted Venture Capital funding because of the reliability of investor returns and the high quality Employment Opportunities it provides. But that also means it is rife with political landmines. Mess with any aspect of that economic juggernaut and you mess , with somebodys bottom line and their lobbyist will be on your doorstep. Our supposedly Consumer Driven Health care economy is a nightmare for consumers to negotiate. Patients trying to shop for a cheaper care are at a tremendous disadvantage. Huge disparities exist in access to care by income level. While such inequities seem tolerable in other aspects of a consumer oriented economy for example, why you buy a luxury their economy car existence in Health Care Makes us uncomfortable. Americans have long had a sense that in a doctors office, people are more equal than anywhere else in the world. We have a set up a system where that ethos is hard to honor. Our faith in marketization is one reason. Why are the alternatives so hard to envision . I will hand the microphone over , who isiend beatrix going to help you understand that. [applause] thank you for being here. It is a privilege to be here. The question i am going to look at today is why have we not as a nation been able to reach a political solution to the persistent problems that have the problems of high cost and millions of uninsured people. But i would like to go back to something nancy said, about the netherlands never worrying about their Health Coverage. This idea of relief from worry or from fear about what will happen to us when we need medical care is the reason Health Insurance was invented in the first place. The reason that over 100 years ago, industrialized countries around the world began to establish a system to protect working people from the high cost of getting sick. It was actually exactly 100 years ago, in 1919, that such a plan came close to passing in new york. This proposal would have provided workers with medical and hospital coverage as well as partial coverage of the wages they lost when they could not work. Supporters of the plan focused on how it would help alleviate some of the terrible fear that working people felt when they contemplated the vulnerability of sickness. They argued that Health Insurance would rob poverty of one of its worst terrors. The bill was sponsored by a popular republican senator and with his help, it passed in the new York State Senate in april 1919 but when it got to assembly, a powerful speaker refused to let it out. His reason was that the Health Insurance bill embodied two other things americans feared the authoritarianism of germany, who we had recently helped where in world war i, social Health Insurance had been invented, and the newer threat of state socialism emanating from the russian revolution. That was the end of the First Campaign for public Health Insurance in the u. S. As you know, this kind of emphasis on the dangers of socialism and the unamerican nature of other countries Health Systems continued to be heard for the next hundred years. There is another way each defeat of universal proposals would make it even harder to succeed the next time around, and that is the way they ended up changing the Health Care System itself. This first fight over public, nonprofit Health Insurance led to the idea and growth of private forprofit Health Insurance. The biggest opponents of the legislation back in 1919 were employers who did not want to pay a share of the cost and doctors who were worried they would lose their independence, and also Insurance Companies. Commercial insurers had never offered Health Coverage before. It was seen as too risky. They fought the new york proposal because it included Life Insurance benefits that would have been in direct competition with their business. In working to defeat the legislation, the Insurance Industry became aware of a new potential market for their product. Here is what one insurance executive said in 1917. Health insurance is engaging the interest of all our legislators and we should be in a position to meet their socialistic ideas by offering a good brand of sickness protection such as we know can be profitably written in a larger volume. The Vice President of prudential agreed that all the arguments in favor of compulsory Health Insurance would be met by such innovation. We will see this pattern again in all the other campaigns for reform. Private industry creates mechanisms that will partially meet the need for security but they are designed to prevent universal programs from being passed. These private marketdriven developments were also political. Private Health Insurance did not take off until the 1930s but its birthplace was in the fight over state level legislation in the 1910s. In the 1920s and 1930s, the focus shifted from lost wages to the need for medical care itself and during the depression, reformers pushed Franklin Roosevelt to make this part of his Social Security act. He decided against it, worried that doctors opposition would derail other new deal priorities. But ideas change during world war ii. By 1944, he was proposing a second bill of rights which included medical care as a right. After his death, truman continued with that idea and pushed congress to Pass NationalHealth Insurance, which would have fulfilled fdrs promise by expanding Social Security to include Health Coverage. National Health Insurance was part of trumans larger Health Agenda that included federal Hospital Construction and expanded support for medical research. Unlike earlier proposals, trumans was universal and would have covered everyone. Polls show that initially, the majority of the public supported the idea of Health Insurance for all via the Social Security system. Hello. There is nobody there. But this was also the start of the cold war. When hearings began, Senate Leaders called trumans planned the most socialistic measure that this congress has ever had before it. This kind of attack was familiar from three decades earlier, but something new was that the American Medical Association ran a campaign telling the public to fear socialized medicine. This was the first pr campaign of its kind. It may have been the most successful, because after three years, public support went down to 20 and trumans plan for National Insurance never made it to a vote. Again, the reaction change the changed the Health Care System. Congress agreed to just one part ,f trumans Larger Program federal funding for Hospital Construction. This was the the hill burton act of 1946, which opponents supported because it provided for construction only with no other type of federal involvement. Hill burton maintained local control so much that it preserved the right of communities in the south to use federal taxpayer funds to build segregated hospitals. Southern democrats supported the legislation, even if they opposed the national Health Insurance plan. Years, hillt 25 burton funded a third of the hospitals built in the u. S. And brought medical care within reach of millions of people, but the choice of centralizing medical care in the hospital while not passing universal coverage or building primary care made health care more expensive. It also created the hospital lobby and the industry became a powerful Political Force in health care debates. The growth of hospital care in the absence of universal coverage also led to the growth of private insurance to pay for all that care and in the 1940s, insurance became tied to employment as firms offered Health Benefits instead of higher wages in world war ii. In 1943, the irs encouraged this by making benefits tax exempt and congress made that permanent 10 years later. Just as hill burton subsidized private hospitals, federal tax policy gave Government Support to private insurance by certain sponsored by employers. The jobbased system grew until three quarters of the population had some coverage by 1960 a. Just as the Insurance Industry had hoped, private insurance served a political function by presenting what seemed like a private sector solution to the problem of health and security. Private insurance received via the workplace had some major problems. Obviously it did not cover , people without jobs. It also failed to reach millions of americans in lowwage employment, the very poor, and retirees. It became clear that private insurance was not covering enough of the population to provide real freedom from fear of sickness. In backing medicare, jfk and john f. Kennedy and Lyndon Johnson avoided the opposition of Insurance Companies because medicare would cover only those people that private insurance could or would not, the elderly. In one of his speeches lbj , returned to the theme of freedom from fear and destitution. With medicare, he said older , citizens will no longer have to fear that illness would wipe out their savings and destroy lifelong hope of dignity and independence. Medicare did take a page from trumans book because it was built on Social Security s administrative structure, a program that was familiar and popular area this also made it harder to attack. The ama did try one more time. They hired Ronald Reagan to record a speech in which he insisted that medicare would lead to fullblown socialism and the end of freedom in america. This time around, the ama lost. But as nancy told us, the fear of socialized medicine and power of the medical profession, hospitals, and the Insurance Industry shaped how the Medicare Program was designed. Providers could charge whatever they wanted. Fear of a provider backlash led to the absence of any cost control or budgeting in medicare. Alongside growing costs, unrestrained medicare payments to doctors and hospitals drove a rise in National Health expenditures after 1965. Medicare did succeed in at least partly addressing the fear that sickness can devastate us financially and physically. Seniors gained a kind of Health Security no one else in the population had. Many of the time thought that medicare would be the first step toward a similar security for all americans. Instead, by essentially giving check,rs a blank medicare would make it more difficult to pass cumbrians of reform in the future because after 1970, the goal to expand the number of people covered was overwhelmed by the imperative to control cost. As medical inflation in the 1970s grew, employer Health Benefits begin to contract. This is when we see the huge numbers of uninsured americans becoming the main drivers for health care reforms. By the mid1980s, nearly 80 of 18 of the nonelderly population had no Health Insurance at all. There was a crisis in uninsured patients being turned away from hospital Emergency Rooms, transferred in fatal or unstable condition. A situation got so terrible that congress did act to pass the emergency medical treatment act in 1986 that at least guaranteed one right to access Health Care System in the emergency room. Studies began to show what many people already knew. Being uninsured could lead to not just bankruptcy but debility, suffering, and death. Clinton in 1993 and tried to 1994 address the crisis with a plan for universal coverage but regulatedthrough Insurance Networks but that also failed to reach a vote. Like earlier defeats this led to , a major structural change in Health System and this was the , spread of managed care as an attempt to contain costs. In the 1990s and 2000s, many insured americans had to accept a new kind of health plan that severely narrowed their choice of doctors and hospitals and severely narrowed their choice of doctors and hospitals, imposed extensive costsharing and deny them care. Pretty soon, it seemed like everyone had a health care horror story with Insurance Companies refusing to pay for preexisting conditions, choosing between paying for food and medications, and families being driven into bankruptcy after reaching coverage limits. Theit encompassed not just problem of the uninsured but the devastating experience of people with insurance. This explains why the directors of the Affordable Care act focus partly on extended coverage, but especially issues like guaranteed issue, ending exclusions for preexisting otherions, and ending long practices of Health Insurance. At the same time, the ada guaranteed that private insurance would continue networks of providers, and more and more costsharing for patients, features that reduced choice and affordability. Since tenney since 2010, millions more have insurance and that is an historic achievement but that does not give them full fear and of course, 27 million in this country are still uninsured. The ceo of gofundme announced that one third of the 5 billion raised on the site each year is for peoples medical expenses. A lot has changed in 100 years, but i guess some things have not. During my research, i learned about a practice that factory workers had in the early 20th century. Passing the hat around the shop for the benefit of some sick worker. One woman said a collection was taken practically every week in eight of her coworkers facing sickness. The u. S. Health care system still does not protect americans from fear of poverty or bankruptcy from getting sick. Thank you. [applause] i would like to thank both of our speakers. Pass your card with questions to the aisle. Ok. This one. T with the u. S. Healthcare system has been based on workplace insurance. What implications does this have for women, especially in the time before they entered the workforce and large numbers . Oh, excellent question. Women are more likely to not have Health Insurance for that very reason. But there are also ways women were discriminated against in employer and Health Insurance. It was very uncommon for any plan before the late 1970s to cover Maternity Care in childbirth because Insurance Companies thought that people should not buy insurance if they thought they were going to use it, and since pregnancy was always, a planned condition, that was not an insurable condition. So women were both uninsured and underinsured in great numbers. The u. S. Leads the world and medical research. Our Companies Like the netherlands able to make similar advances without market based incentive to do so . Is yes. Nswer to that one of the myths about the american way is this is the only way to get innovation, but in fact, theres not good evidence that this is the only way to get people to innovate and come up with new approaches. , there are ways the american system produces innovation that European Countries are interested in in terms of how we manage medicine because our system is so complex. Myths ur management but i think the only way you can get progress is through the thought that the only way to get progress is through our specific model is not mourn out through the history of scientific innovation, medical innovation. I would add to that, the innovations the u. S. Is so famous for, they were publicprivate partnerships. The nih, the National Cancer institute, that funds innovation with the private sector, so its really been a publicprivate partnership. Ok. Much of current concern about u. S. Health care focuses on high drug costs. Is this a new phenomena and or does it have deeper historical roots . A new phenomenon. Wheren interesting area Prescription Drugs in particular draw a system of drugs dependent on the use of patent protection to encourage innovation and the developed insystem the early world war ii, 1950s, but it really set up a system incentivized innovation, but protected it in a way that made for a very high cost in terms of Prescription Drugs. The cost of Prescription Drugs thealready an issue by 1950s. Price were finding the very hard to bear and of course, medicare did not cover Prescription Drug costs until very, very recently. This is been an issue for a length of time. When people talk about federal involvement in health care, they usually think of medicare and medicaid, but Veterans Affairs also offers governmentfunded health care. How did it arise in what lessons can offer us . Great question. An excellent question because in some ways we have had socialized medicine for veterans since at least world war ii. The v. A. Has gone up and down in terms of its ability to provide well for our servicemen and. Heir families in some ways, it became a poster child for years of the heavyhanded government bureaucracy and how it would retard innovation, but its problems were simply if you set up the system and do not not it enough money, its going to perform well. There are a lot of lessons to learn there and historians of the v. A. System can i can recommend their work to you, it is fascinating stuff. Do either of you know how the ama has responded to calls for national Health Care System today . Prof. Hoffman the position of the ama is very interesting. As youve heard they were very unified in a position to universal programs up through medicare and that was really the last ditch attempt to oppose a national reform. Doctors views started to change. Not necessarily reflected by the ama. But by the time of the clinton debates in the 1990s, physicians were more divided than they had ever been. They wanted to preserve their independence, the ability to Practice Medicine as they saw fit, but by the 90s, many practicing under Insurance Companies. They were not independent anymore. And creating a system where everyone would be insured and word remove the barrier between dr. And patient the Insurance Company had become. Insome provider groups family medicine, emergency medicine, pediatrics have come out more strongly since the 1990s in favor of universal plans. The ama today is back to its old tricks when it comes to advertising. I see the advertising being put out against the medicare for all idea. It seems to me the ama is coming out against the proposals for singlepayer, but that should not lead us to make assumptions about what a physicians opinion position is because physicians are more diverse and their organizations are, too. There is no one position position on anything, and there was not in the past as well rid there were always doctors who were critical of that feeforservice system. And that predicted the problems that would arise with that. Hisone of the major divides around primary care physicians. Their position has eroded dramatically since world war ii. Provide general, disadvantagee at a and they are much more interested in positions that might shift back. They shift the specialist back to the generalist. There are european systems where its much tighter, where you cannot just go to a specialist anytime you decide to. Prof. Kraut one of you mentioned unions. Do you think the incline of union powers is connected to the labor crisis . Prof. Tomes yes. I mean, there is a long history we cant get into in terms of how organized government helped collective bargaining process. It left out women. It left out people of color. It kind of shot itself in the foot. Economy isustrial organized around the service industry. Are players in terms of trying to change the issuance system, but certainly back in organized labor organized, having they had more clout than in the 1970s. And they had better rates than blue cross blue shield. That may be became tarred with the brush of that is just communist medicine. They were tarred with that brush taking them down the road to the evil empire dominance. Do you think the examples of European Countries are fully applicable to the United States in spite of having much smaller populations . Prof. Tomes point taken that the netherlands is these size of maryland. If you look at germany, that is a much bigger country with a. Arger population i do think the United States could learn a lot by looking at how our capitalist democratic nations have managed the you rise of a new medicine since world war ii. It is correct but not everything is going to be applicable, but i think trying to get a sense of why cultural preconceptions are so different, in my work, i have e to see world war ii countries like germany and the netherlands were destroyed. Of they had a sense of rebuilding and solidarity you simply do not see in the United States. In world war ii, but we did not come out of it with the same sense of having to rebuild from the bottom up. I think theres a lot we can learn, but your question implies its going to be selective because in a lot of ways are examples are not comparable. The systems in europe are also very diverse. We can look at different models. Theres one thing they all have in common that we can apply anywhere, regardless of insurance. They all have in common that everyone is covered. Every resident in the country is covered, and that leads to a pooling of list, and the other in common, all the patients are in the same system and all the providers are which can beystem, applied to any country of any population. Prof. Kraut many wounded veterans got excellent medical care and they wanted that for themselves and their amylase, no matter what it would take to do that. It was the First Experience that americans had of Excellent Health care. It just didnt proceed succeed. There was also socialized medicine during world war ii briefly. Maternity care for soldiers wives. It was only temporary. Prof. Kraut this is near and your team my heart. How do you think historical scholarship can be a useful tool to inform and help with decisionmaking by policymakers . Prof. Tomes ay yi yi. Prof. Hoffman i think we have to look at history to have an honest conversation about whats happening now. We hear todayric is not based in accurate descriptions of the u. S. Health care system. So, we have to understand, what are the definitions . . Hat do we mean how do Foreign Countries actually do what they do . , if i can talk about our profession, does a good job providing accuracy in debate, so lets hope for that. Prof. Kraut history always helps. Prof. Tomes it does. Key israut if the reforming private insurance, how do we go about doing that. [laughter] prof. Kraut saves the toughest for last. Prof. Tomes its the question of how you change the system when you have such a powerful Economic Investment . And how many people work in the private Insurance Industry . If we went tomorrow to medicare for all, the singlepayer government runs the stone, how many people would be out of a job . Theof the arguments for system i described was the ithpaying employment produced. Know, there are administrative costs. They are the highest in the universe probably. We invest a huge part of our health care dollar in that management. And we feel ideologically. Uperior changing that is really going to more and more brokering of economic interest so the coulde Insurance Industry accept the change. Its one reason i personally do more stepwise plan is likely to work because they are not going to go away. But maybe you prof. Hoffman if we really Want Health Care to be more affordable, it is hard to see a role for private insurance as it now exists. Besides ours that include a role for private companies, most of them are actually nonprofit they are private, but they are nonprofit. If you take out the profit , it will reduce administrative costs and overhead. Toward thinking private insurance it will be difficult to find insurance through that entity because they currently have too much say in our politics. They may be a stakeholder, but the main stakeholder is the people of this country. So, they should have less of a say in how we develop our system. I would say one characteristic of our european more is they tolerate government regulation, providers, prices, who gets what care. Until we accept the government needs to regulate and i mean heart regulation, these problems are impossible and we are clearly not to that place. Prof. Kraut a change of consciousness . Prof. Tomes yes. Prof. Hoffman yes. Prof. Kraut time for one or two more. How have the relationships of state with health care evolved over time . Prof. Tomes great question. Health insurance debates began at the state level. State almost entirely proposed. The role of the states was, of course, preserved in medicaid, and i know theres a lot of hope state improvisation. Inequityeally a lot of in the system because theres so much differential between states in terms of medicare benefits, in terms of who they cover. The states certainly have a role to play. But they have also had a big role to play in preserving inequity in our systems. Prof. Tomes on a more optimistic note, there is the potential for states to try out different funding schemes. And it shows a move toward a more europeanstyle model might if you can make it work in massachusetts, in washington state, that could possibly influence federal policy. Thats an optimistic view. Last question. What common themes have you observed rub the his three of health care regarding what seems to be problematic and what creates progress . Prof. Tomes go for it. Prof. Kraut go for it. Prof. Hoffman the problems are easy. Thats mostly what we talked about. The thing that keeps coming up over and over again is the distortion in the debates of the debates take place politically are not they distort the reality of our Health Care System. Discussion ofst how we deliver healthy or in the country and that was necessary to change it. One of the lessons i have learned is the dangers of and thedividualism importance in health care of having a sense this is quoting, a recent commentator that america has lost its sense that we are all in this together and we do not have a sense of solidarity. Friends aree my like, what is wrong with you people . If that hyper individualism. The worst thing you can do for the american character would be to relieve people of the fear their health care would be covered. You would all be lazy, unmotivated people. Thats a lot of the ideology that drives this. The fear of a welfare mentality taking over. Be your going to family. Streetfamily across the whose skin is a different color or perhaps did not grow up in the United States. Individualism versus solidarity. Are we all in this together . Take question. One example of success, something that has worked is not a topdown process. Attributede is often to Lyndon Johnson and his negotiating prowess. He was amazing. But he was pushed by the Civil Rights Movement and senior , they put it back to the people organizing. Excellent answers. Tough questions. Thank you all for coming this morning. [applause] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] [captions Copyright National cable satellite corp. 2019] and now, you are watching American History tv. We bring you 48 hours of programming exploring our nations past. American history tv, only on cspan3. This weekend on american artifacts, we visit the National Archives in washington, d. C. , to tour american women and the vote. Here is a preview. I am karine, a curator at the National Archives museum. I will show you around the rightly hers exhibit today. Before we head into the gallery, one to talk about the lobby and the entrance. Photograph of the 1913 womens suffrage march, looking up pennsylvania avenue towards the United States capital, and it is overlaid with a photograph march from17 womens pennsylvania avenue, as well, and it has a special effect as you walk by. The image changes between two. We really wanted to have it in the exhibit to grab the publics attention and also signal that but is an historic exhibit, one that continues to have temporary relevance today. Laurensad now into the ethyl gallery, where rightfully hers is displayed. This is the National Archive exhibition to celebrate the 100th anniversary of the 19th amendment, but it is more than the 19th amendment exhibition. That is because the 19th amendment, landmark Voting Rights victory that it was for women, did not give all women the right to vote. By thee already voters time it was added to the constitution, but millions of women, for reasons other than their sex, remained unable to vote. So this exhibit looks at that story, as well. We have this introductory video meant to grablso peoples attention and pull them into the gallery. It also gives you a sense of what types of stories you are going to encounter here in the rightfully hers exhibition. The exhibit is ordered into five sections that asks five questions, which you can see here with the women who are carrying their protest banners. Those questions are, who decides who votes . Why do women fight for the vote . How did women win the 19th amendment . What was the 19th amendments impact . And what voting