Topics include the roots of the modern Health Care System, the medical bills transformation into a business, and disparities in insurance coverage. The Natural HistoryCenter Hosted the event. I think we will try to start the event on time. My name is dane kennedy, director of the National History center. I want to welcome you all to this briefing of the history of u. S. Health care and health care policy. This is a briefing sponsored by the National History center, which is affiliated with the american historical association, and is part of a series of briefings that we offer that provide historical perspectives are issues that are currently confronting congress. We will have another one at the end of next month which would be a 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 met to give greater insight to how we got to where we are, which we believe helps us to understand how we can solve problems. A few things, that i will turn it over to alan. First of all, the. Carnegie Mellon Foundation funds this program. We are very grateful to them. Secondly, a room has been booked for us by congressman gerry connollys office, and we are grateful to them. I would also like to thank my assistant director jeffery gardner, who is in the table outside and will be coming in shortly. Now we turn it over to professor alan kraut from the American University who will moderate the event. Me say, mostthat of you will find these index cards on your seat. That asnt of these is the discussion proceeds, if you have questions, write them on these cards and we will collect them after formal remarks and use them to initiate the discussion. All right . Think about that as they are giving their remarks. Alan . Dane. Thank you, good morning. In 1941, the influential declared henry louis 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 science industry, in discovery and research and vaccine development, and surgical innovation, the United States was and remain 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. The father of modern transplantation performed the first human liver transplant in 1963. Then there was the miraculous benefits of the human genome project at the National Institute of health. The problem is that the wondrous results produced by american researchers, surgeons, epidemic fighters, was not always accessible but the American Population broadly and equitably. Too often, health care in the United States was among the privileges enjoyed by the sealthy for in postwar american who had access to a Good Health Insurance policies, many purchased in the workplace. After the birth of the blues in the midcentury, and of course, i mean the cross and blue shield labor unions and private, employers negotiated medical plans for their employees. However, 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 care. Americans4. 2 million were without Health Insurance, 17 of the population. The Affordable Care act reduced int to just below 27 million 2016. Broadening the ability of americans to access Quality Health care has not been easy because unlike many of the countries throughout the world, the government of the United States long remained distant from caring for individuals not in the uniform of the United States military. 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 Freedmens Bureau after the civil war. However, for the most part, congress has resisted initiative to involve the government and Offering Health care or insurance to any but the military. Few americans realize that it was the process the vociferous Theodore Roosevelt who was the first to unsuccessfully but passionately advocate for national Health Insurance in the first decade of the 20th century. Franklin, aousin democrat and later still, harry truman, 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 offered a fresh path to relieving the anxieties of those shot out of Health Insurance shut out of Health Insurance and the Health Insurance market. However, many issues remain. Where are we now . How can history help us . America,d states of the richest and most medically accomplished country in the globe has still to solve many problems. The American Population suffers from some of the highest Health Care Costs on the planets. According to 2017 estimates, we spend 3. 5 trillion every year, around 17. 9 of the gdp, and about 10,739 each year in Health Care Costs per person. But it is doubtful whether this high expenditure translates into true patient care and health care outcomes. The commonwealth fundss 2018 study of 11 countries, including australia canada, france, the swedenands, norway, switzerland and the u. K. Lastd that the u. S. Ranked 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, for access to primary care in the u. S. Has contributed to inadequate chronic disease prevention and management. Delayed diagnoses and safety concerns, among other issues. Much of the care accessed by americans is inadequate to their need. Prices of pharmaceuticals are sky high as compared to other countries, especially for lifesaving drugs such as insulin. The population of the country remains underinsured as of the political debates of different approaches sizzle in the prelude to the next election. Everything has a history. That is our motto at the National History center. Everything has a history. Before we can get to a better place, we need to understand how we came to this path, and where 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. Fortunately, we have two superb historian 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 before we can intelligently navigate successfully through the rough waters of social and political debate that lay ahead. Our first speaker this morning statefessor nancy tomes, university of new york distant wish professor at Stony Brook University, author of 4 books, a generous confidence, the art of asylum giving, published in 1984, madness in america, cultural and medical perceptions of Mental Illness before 1914, a coauthored work, the gospel of life, and, women and most recently, how madison avenue and modern medicine turned patients into consumers, 2016. The gospel of germs, she won both the American Association for the history of medicines medal in the history of Science Society prize. The American PublicHealth Association awarded her an award for her distinguished body of scholarship in the history of public she received the very prestigious bankrupt prize for distinguished work in American History for remaking the american patient. Our second speaker this morning who teaches hoffman at Northern Illinois university where she is heinz fellow in in theaduate teaching humanities. She is the author of two books on the u. S. Health care system. Of andthe Politics Health care for some, rights and rationing in the United States. Volume a coedited patients as policy advocates. She has published many articles dealing with areas aspects of the Health Care System from the history of Emergency Rooms to the origins of copayments and adaptable. Her work has been supported by the National Endowment of humanities. Johnsonrobert wood foundation. And she has received a broad recognition in many ways. In 2015, she gave the commencement address at Loyola School of medicine in chicago. And so, it is with great firstre that i introduce the professor to come to the podium. Thank you. Thank you for that nice introduction. To focus on one unique feature of health care. That we think of health care primarily as a commodity. It should and must be delivered according to market east principles. Through our feeforservice system, providers breakdown medical care in Component Parts and charge for each product and service separately. Is each stage of care, it accepted that someone will make a profit doing so. Building a robust profit into supposedly driving the system to offer more and better care. Since the ultimate purchaser of patient,ces is the Better Health as well as profit taking involves getting people to purchase 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 cult am referring custom of to patients and Health Care Consumers and doctors as health care providers. At this point, many of you are probably thinking of course. This is how modern medicine works. Doesnt everyone think this way . In fact, no. You discover that they do not market ties health care tize health care. Over the past two years, i have spent a lot of time in the netherlands. About as pragmatic and capitalist a nation as you will want to find and they are baffled why two traits of the american way of medicine. The aggressive use of marketing with advertising and the resistance to giving all citizens Health Insurance. One of the most distinctive traits of American Health care heavy reliance on sophisticated marketing and advertising. If you watch network tv, you are familiar with one such promotion. Zealand is the only other country in the world that allows this kind of advertising. Anywhere 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, which brand of pacemaker a doctor chooses. A hefty chunk of money goes to advertising hospital chains and highvolume medical procedures. Such as lasix. Our european peers look at all of the money spent on marketing and advertising designed to promote the newest and most expensive medicine, and say, no wonder you cannot ensure inshore insure everyone. Advanced biomedicine in other countries is expensive but somehow they managed to control the cost and provide almost universal access. When i visited the netherlands, their hospitals are exactly like ours. But no advertising. All citizens are covered. The dutch were not worried about their Health Insurance, it is hard to believe. And the most heartbreaking teacher of the u. S. Situation is how we spend more money per person but do not seem to reap commence or it benefits. Benefits. Urate if you are interested, we can provide links to more studies. Why do we have this system, and how do we fix it . A lot of debate in the u. S. Focuses on the role of the federal government. Does the medical marketplace work badly because the government interferes too much or too little . It is useful to turn back the clock. What was health care prior to 1965, the year the federal government got into the business of funding medical care to medicare and medicaid . Today, i will provide a brief answer. I will show the downside of our heavily marketed system, inflated prices, and lack of access, were all evident by 1960, the first year the u. S. Health care system was declared to be in crisis. That crisis led to the federal government getting involved, ostensibly to correct for market failures. It did not work out so well either as beatrix will to you more about. 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. In the colonial era, guild regulation of medicine did not survive the transfer to the new world. Colonialism encouraged the motto every man his own doctor and the forerunners of todays physicians faced competition from alternative healers. You could make drugs in claim they cured cancer and there was no fda to tell you no. The medical profession was given powers to regulate itself in government got basic powers to require accurate labels on drugs. More scientific medicine yielded new diagnostic tools like the xray and new treatments, such as aseptic surgery. Regular doctors, the ancestors of todays biomedicine, provided services to their patient. The hospital became known as the doctors workshop and the surgical amphitheater where germfree, pain free surgery could now be performed. As the medical profession gained respect, it got more control over licensing, making it harder for alternative healers to compete. This new medicine required more education and technology. So it 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. As beatrix will explain, 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. Professional as well as 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 concerned people, setting the stage for a new product designed to provide security against health catastrophe, the private insurance policy. Franklin,ith benjamin americans have loved the concept of private insurance to hedge against bad luck and during the great depression, the insurance habit expanded to include hospital care financed 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 1967, most americans had insurance through their employer. This was set up on a feeforservice basis. Hospitals are doctor hoss hospitals and doctors said, here is what i charge and insurers paid the charge without question. After world war ii and the developed nation peers, began to turn to more government involvement and regulation of Health Care Costs and delivery, what we call socialized medicine. The United States doubled down on privatized system and in the early 1950s, the Congress Said no to national Health Insurance coverage. Yes to more money to build hospitals and fund medical research through the nih. This funding enabled scientists to innovate, hospitals to provide more care and create a Health Care System the u. S. Could be proud of. During the cold war, democrats and republicans bought into the privatized approach. But there were flaws in this Free Enterprise approach that approach. In a consumer driven you dont 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 allows consumer leverage in the marketplace do no