health care policy since world war i. topics include the roots of the modern health care system, medical field's transformation into a business, and disparities in insurance coverage. the national history center hosted this event. >> i think we're going to try to start this event on time. my name is dane kennedy. i'm director of the national history center. i want to welcome to you all to this briefing of u.s. health care, health care policy. this is a briefing sponsored by the national history center, which is affiliated with the american historical association. and it's part of a series of briefings we offer that provide historical perspectives to issues that are currently confronting congress. we will have another one at the and of next month, which will be 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 i'll turn it over to alan. first of all, the mellon foundation funds this program. special things to them. -- thanks to them. secondly, the room has been booked for us by congressman jerry connolly's 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 giving 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 , 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 mid-century, 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 middle-class 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. 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 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 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 military. 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. johnson's 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 -- the united states of america, the richest country on the globe, has still to solve many problems. 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 it's doubtful whether this high expenditure translates into true patient care and health care outcomes. the commonwealth fund's 2018 study of 11 countries, including australia canada, france, the netherlands, sweden, switzerland and the u.k., found that the

the population of the country remained underinsured as political debate approaches. everything has a history. that is our motto at the national history center. before we can get to a better place, we need to understand how we came to this past and why, why do 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 historians who can lead us through that tangle that has been the history of health care in the united states.

we need to know that pass -- past before we can intelligently navigate successfully through the rough waters of social and political debate that lay ahead. our first speaker is a professor at stony brook university. she is the author of four books, "a generous confidence." and the art of asylum keeping, published in 1984. madness in america. cultural and medical perceptions of mental illness before 1914, a co-authored work. the gospel of germs, men women and the microbe in american life, and most recently how madison avenue and modern medicine turned patients into consumers. 2016. germs, gospel of professor tomes won the american association from the history of american's welsh metal.

in 2011, the american public health association awarded her the award for distinguished scholarship in the history of public health. and most recently, in 2017 she prestigious very bancroft prize for her work in american history for remaking the american patient. our second speaker is a professor who teaches at northern illinois university. where she is heinz fellow in undergraduate teaching in the humanities. she is the author of two books on the u.s. health care system. and health care for some in the united states since 1930, 2012. as well as the co-edited volume,

patients as policy actors. she has published many articles dealing with various aspects of the health care system to the origins of copayments and deductibles. the work has been supported by the national endowment for the humanities. the american council of learned societies. and she has received broad recognition in many ways. in 2015 she gave the commencement address at the school of medicine in chicago. it is with great pleasure i introduce first, professor tomes. please come to the podium. tomes: thank you for that nice introduction. we think of health care primarily as a commodity, a set of products and services that should and must be delivered according to market-based principles.

through our deeper service system, medical providers break down into component parts and charge for each service separately. in each stage of care, it is accepted and encouraged someone will make a profit doing so, building a robust profit 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 profit-taking 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. some of you will or all are likely thinking, of course, that is how modern medicine works. doesn't everyone think that way?

in fact, no. investigate other advanced capitalist democracies and you discover they do not market ties health care to the extent the u.s. does, nor do they refer to patients as health care consumers. because of not -- my work, i now get invited to speak abroad precisely because people in these other countries are merificationt consu of u.s. health care. over the past two years i spent a lot of time in the netherlands about a capitalist a nation you will ever want to find, and they are baffled by two traits of the american way of medicine. the aggressive use of marketing and advertising and the resistance of getting citizens health insurance. one of the most distinctive traits of american health care is its heavy reliance on 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. anywhere else it is thought to be an inappropriate invasion of the doctor-patient 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 so-called physician preference items, which brand of pto ress releases -- hip rosthesis and pacemaker a doctor chooses. a hefty chunk of money goes to advertising hospital chains and high-volume medical procedures. our european peers look at all of the money spent on marketing

and advertising designed to promote the most new and expensive medicine, and say, no wonder you cannot ensure everyone. to be sure, 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. 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 commensurate benefits. 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? 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 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. 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 heavily market eyes health care system? ized health care system? 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 today's physicians faced competition from alternative healers.

you could call yourself a doctor and the association could do nothing about that. you could make drugs in a barrel and claimed they were a cure for cancer, and no fda was there to tell you no. the medical profession was given powers to regulate itself in government got basic powers to require accurate labels on drugs. one reason for the incomplete medical freedom was the rise of a more scientific medicine that yielded new diagnostic tools like the x-ray and new treatments, such as aseptic surgery. regular doctors, the ancestors of today's biomedicine, provided services to their patient. the i kind of this new medicine of this newcon

medicine was the hospital became known as the doctors workshop and the surgical amphitheater where germ-free, 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 fee-for-service system, doctors began to pass costs onto the patient. there was no third-party system. the doctor gave you a bill and you paid it. alternatives to fee-for-service medicine were proposed and defeated over and over in the 20th century. medical practice remained highly competitive and to do well, doctors had to be medical professional and modern businessmen. they sought to attract patients who could pay and started moving out of low income neighborhoods.

in search of the better paying patients. 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 and 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 habit 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 1967,

ofthat by 1960, 72% americans had insurance through their employer. this was set up on a fee-for-service basis. hospitals are doctor 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 regulation of health care costs and delivery, what we call socialized medicine. the u.s. double down on privatized system and in the early 1950's, the congress said no to national 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 approach. that you don't 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 not work well in health care. medicine embodies an asymmetrical relationship. the doctors knows more than you do and has special powers to direct your care. when it comes to the most effective treatment, the ones who could really save your life, the doctors have to order them for you. i cannot walk into a hospital and say, hook me up to an iv. professional ethics are supposed

to prevent the doctor from overruling, and yet the way the american health care was market ties to 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. doctors and hospitals charge higher prices, assuming patients had insurance to cover the cost. as pharmaceutical companies and device makers competed to offer doctors new products and services, planned obsolescence became a byword in medicine and while encouraging innovation and high-tech care, the system set spiral ofationary costs. generalists who saw their patient saw incomes plummet and

specialists did not. this led to the overuse of surgery and prescription drugs and elderly and low income people lacked health insurance. by 1960, politicians and journalists began to use the word crisis to describe the health care scene. the care of the elderly and low income, the federal government got into the business of health care in 1965. to gain support for these programs, lyndon b. johnson agreed to set it up with all the same built in triggers incentive for more expensive care and what the market will bear approach to pricing, we are seeing inflationary spiral again today. 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 not reached a form of cost-cutting. this resistance has grown as the u.s. has moved from an industrial to post industrial economy. in the late 20th century. health care has become a major economic engine in the u.s. 20% of our gdp. it has attracted venture capital funding because of the reliability of investor returns at high quality employment opportunities. but that also means it is rife with political landmines. mess with any aspect of it, and you mess with somebody's bottom line and a lobbyist is on your doorstep. own doorstep. this is a nightmare for consumers to negotiate. patients trying to shop for a cheaper care are at a tremendous disadvantage.

americans have long had a sense that in a doctor's 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. why are the alternatives so hard to envision? i will hand the microphone over to my friend beatrice who will help you understand this. [applause]

>> thank you for being 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 problems that have been described 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 fear about what will happen to us when we need medical care is the reason health insurance was invented in the first place. 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 exactly 100 years ago,

1919, that such a plan came close to passing in new york. this would have provided workers with medical and hospital coverage as well as partial coverage of the wages they lost when they cannot 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 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 othernce bill embodied to

things that americans feared including the authoritarianism of germany, 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 un-american 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. the first fight over public, nonprofit health insurance led to the idea and growth of private for-profit health insurance. the biggest opponent of the

legislation 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 interest of all legislators and we should be in a position to meet their socialistic ideas by offering a good brand of sickness protection that we know can be profitably written in a larger volume. vice president of prudential agreed in favor of compulsory health insurance 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 market-driven developments were also political. private health insurance did not take off until the 1930's but the birthplace was in the 1910's. in the 1920's and 1930's, 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 the idea and push congress to pass national health insurance, which would have fulfilled fdr's promise by expanding social security to include health coverage. national health insurance was part of truman's larger health agenda that included federal hospital construction and expanded support for medical research. unlike earlier proposals, truman's 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 social security system. but this was also the start of the cold war.

when hearings began, senate leaders called truman's plan the most socialistic measure this congress had ever had before it. this attack was familiar from three days earlier and something new that the medical american 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 truman plan for national insurance never made it to a vote. again, the reaction change the health care system. congress agreed to just one part the hill burton act of 19 46 was supported because it provided for construction only with no other type of federal involvement. hill burton maintained local control so much, he 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 oppose the national health insurance plan. over the next 25 years, burton -- hill burton funded a third of the hospitals built in the u.s. and brought medical care within reach of millions of people without passing universal coverage or building primary care making 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 the care and in the 1940's, insurance became tied to employment as firms offered health insurance. instead of higher wages during world war ii. in 1943, the irs encouraged this by making benefits tax exempt and congress made a permanent 10 years later. just as hill burton subsidized private hospitals, federal tax policy gave government support to private insurance by certain employers.

the job-based system grew until three quarters of the population had coverage by 1960. 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 has major problems. it did not cover people without jobs. it also failed to reach millions of americans in low-wage 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 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. 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 truman's book because it was

built on social security administrative structure, a program that was familiar unpopular. it also made it harder to attack. the ama did try once more. they hired ronald reagan and in a speech he insisted that medicare would lead to full-blown socialism and the end of freedom in america. this time around, the ama lost. but 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. because fear of provider backlash led to the absence of budgeting and medicare. -- in medicare. alongside growing costs, unrestrained medicare payments to doctors and hospitals drove a

rise in 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 thought that medicare would be the first step toward similar security for all americans. instead, by essentially giving providers a blank check, and a care would make it more -- medicare would make it more difficult to pass comprehensive 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 1970's 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 mid-1980's, nearly 80% of -- nearly 18% of the nonelderly population had no health insurance at all. there was a crisis in uninsured patients being turned away from ers, transferred in fatal or unstable condition. a situation that got so terrible that congress did act to pass the emergency medical treatment act in 1986 that at least guaranteed a right to access and the health care system in the er. studies began to show what many people already knew. being uninsured could lead to not just bankruptcy but debility, suffering, and death. clinton tried to address the crisis with a plan for universal coverage but this time deregulated the insurance network. it failed to reach the vote. this led to a major structural

change in the health care system and this was the spread of managed care as an attempt to contain costs. in the 1990's and 2000's, many insured americans had to accept a new kind of health plan that severely narrowed their choice of doctors and hospitals and posed expensive cost-sharing and -- imposed expensive cost-sharing and sometimes denied them care. soon it seems like everyone had a health care horror story from insurance companies refusing to pay for care for pre-existing conditions. of people choosing to pay for food or for medication. families were driven to bankruptcy after reaching coverage limits and the focus of the effort changed to encompass the problem of the uninsured, but sometimes the devastating experience of people with insurance. this explains why the drafters of the affordable care act focused partly on expanding coverage but especially on provisions like guaranteed issue, ending provisions for pre-existing conditions and other practices of private

health insurance. the aca subsidized the same private plans to guarantee private insurance would continue as the centerpiece of the u.s. health system. the evidence so far, as well as historical experience, tells us the affordability and private insurance is an elusive goal. instead, in both the aca and employer coverage, we are seeing more plans with narrow networks of providers and more cost-sharing for patients reducing choice and affordability. since 2010, 20 million more people have insurance that didn't have it before. that is a historic achievement. but the insurance does not give them freedom from fear. 27 million in this country are

still uninsured. recently, the ceo of gofundme announced one third of the $5 billion raised on the site each year is for medical expenses. a lot has changed in 100 years. but i guess something has not. during my research i learned about a practice that factory workers had in the early 20th century. the common custom of passing the hat around the shop for the benefit of a sick worker. one woman said that a collection was taken practically every week in the workplace. in eight of home employees facing the high cost of sickness. 100 years after we began arguing about health reform, the health care system still does not protect americans from fear of poverty or bankruptcy due to getting sick. i hope that looking back at the original purpose could be useful in guiding policy decisions

today. thank you. [applause] >> i would like to thank both of our speakers. if you would, please pass the cards with your questions to the aisle and we will pick them up. ok. let's start with this one. since the u.s. health care system has been based on workplace insurance, what implications does this have for women, especially before they entered the workforce in large numbers? >> excellent question. women were more likely to not

have health insurance for that reason. not being in the workforce in equal numbers to men. women were discriminated against in employer health insurance. it was uncommon for any plan before the late 1970's to cover maternity care and childbirth because insurance companies thought people should not buy insurance if they thought they were going to use it. since pregnancy was often a planned condition, that was not an insurable condition so women were uninsured and underinsured in great numbers. >> next question. you mentioned the u.s. leads the world in cutting-edge innovation. our countries like the netherlands able to make comparable advancements without

market-based incentives to do so? >> yes. i think one of the myths about the american way is that this is the only way to but in fact, there is not good evidence that the only way to get people to innovate and come up with new approaches. now, there are ways the american system produces innovations that european countries are interested in, in terms of how we manage medicine because our system is so complex. some of our management methods are of interest to them. but i think that the only way -- the idea that the only way you can get progress is through is simply notodel borne out in terms of the history of scientific medical , innovation. >> i would just add to that,

the innovations the u.s. is so famous for, they were public- private partnerships. the funding that the federal government started to give to our research institutions, that like the nih and the national cancer institute. that funds the basic research that leads to more innovations in the private sector, so it has definitely been a public-private partnership. >> excuse me. much of current concern about u.s. health care focuses on high drug costs. is this a new phenomenon or does it have deep historical roots? >> not a new phenomenon. it is a particularly interesting area in terms of looking at how government involvement in the regulation of prescription drugs in particular helped to drive a system of drug development dependent on the use of patent protection in order to encourage

innovation. , this systemwas developed in world war ii, early 1950's, but really set up a system that incentivized innovation but protected it in a way that made for very high costs in terms of the prescription drugs. so the cost of prescription drugs was already an issue by the late 1950's, that people were finding this rise in prices very hard to bear. of course, medicare did not cover prescription drug costs, until very recently. this has been an issue for quite some time. >> when people talk about federal involvement in health care, they usually think of medicare and medicaid, but veterans affairs also offers government-funded health care. how did it arise and what lessons can it authorize?

-- offer us? great question. >> 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 their families. in some ways, it became a poster child for fears of the heavy hand of government bureaucracy, how it would retard innovation, but in part, its problems were simply that if you set up a system and do not give it enough money, it is not going to perform well. so there are a lot of lessons to learn. and historians of the v.a. system, i can recommend their work to you. it is fascinating stuff. >> do either of you know how the ama has responded to calls train

for a national healthcare system today? >> the position of the ama has been interesting. they were so, as you heard, they were very unified in opposition to universal programs up through medicare, and that was really their last ditch attempt to oppose a national reform. so after the 1970's and costs started increasing and private insurance increased its role in the system, doctors' views started to change. not necessarily reflected in the ama, which doesn't represent all doctors. but by the time of the clinton debate in the 1990's, physicians were much more divided than they had ever been. and one of the main reasons for that is they had fought national healthcare because they wanted to preserve their independence, their ability to practice medicine as they saw fit. but by the 1990's, many physicians were now practicing

under the thumb of insurance companies. they were not independent anymore. they began to see much more value in creating a system in which everybody would be insured and it would remove the barrier between doctor and patient that the insurance companies had become. so some provider groups in family medicine, emergency medicine, pediatrics, have come out more strongly since the 1990's in favor of a universal plan. the ama today is back to its old tricks when it comes to advertising. i saw some of the new ads that are being put out against the medicare for all idea, so it seems to me that the ama is coming out against the proposals for single-payer. but that should not lead us to make assumptions about what

is,icians' position because physicians are more diverse now than they used to be. >> i want to underline diversity physiciane is no "one" position on anything, and there was not in the past as well. there were always doctors viceical of the fee-for-ser system i described to you, and that predicted the problems that would arise with it. and i would say, today, one of the major divides in physicians opinion is around the primary care physicians. their position has eroded dramatically since world war ii. people who provide general, basic kinds of care are really at a disadvantage in the current marketplace, and they are much more interested in solutions that might shift that.

i talked about the generalist to specialist, shifting the specialist back to the generalist. and that is a big difference in european systems, where the control over specialism is much tighter. you cannot just go to a specialist anytime you decide to. >> one of you mentioned unions. do you think the decline of labor union powers is connected to the health crisis? >> yes. [laughter] >> i mean, there's a long history we can get into in terms of how the organized labor movement helped in many ways to gain health insurance through the collective bargaining process. in a way, because of weaknesses in that organized labor movement that left out women and people of color, it kind of shot itself in the foot. but i think it is revived.

i talked about postindustrial economies organized around service industries. service industry unions have come back, and are players i think in terms of trying to change the insurance system. but certainly, back in the day, when organized labor was seen as not equivalent, but having power like organized business or organized medicine, they had more clout than they did certainly by the 1970's. >> better rates from blue cross blue shield. >> and make it more comprehensive. >> just the size of the membership. >> but that backfired, in that they became tarred with the brush of they are just for communistic, socialistic medicine. so reforms that in european capitalist countries were not seen as red were kind of tarred with that brush of oh my

goodness, you are taking us down the road to the evil empire dominance. >> do you think the examples of european countries are the fully applicable to the united states despite having much smaller populations? >> yes and no. your point is taken. the netherlands is the size of maryland, so the kinds of problems they face are different. if you look at germany, that is a much bigger country with a larger population. i do think that the united states could learn a lot by looking at how our capitalist democratic peer nations have , managed the rise of biomedicine since world war ii. it is correct that not everything will be applicable but i think trying to get a sense of why their cultural

preconceptions are so different. in my work, i have come to see world war ii as the fulcrum that because countries like germany and the netherlands and france were destroyed, they had a sense of rebuilding, of solidarity, that you simply do not see in the united states. yes, we fought in world war ii, but we didn't suffer the same devastation in our own land, and we did not come out of it with the same sense of having to rebuild from the bottom up. i think there is a lot we could learn, but your question implies it is going to be selective because, in a lot of ways, our examples are not comparable. >> just one thing. so the systems that nancy is talking about in europe are also very diverse, so we can look at different models, but there is one thing they all have in common and i think can apply anywhere regardless of population.

some are single-payer, some are multi-payer, some are socialized medicine. what they all have in common is that everyone is covered. every resident in the country is covered, and that leads to a pooling of risk, which helps bring down costs. the other thing they have in common is that almost every provider is in the system, so all the patients are in the same system and all the providers are in the same system, which leads to choice of provider, so those are lessons that can be applied to a country of any population, i think. >> our legacy of world war ii was the fact that many wounded veterans got excellent medical care, and they wanted that for themselves and their families, no matter what it would take to do that. >> that's true. >> it was the experience first americans had en masse of excellent health care. >> that was a source of support

for the truman-type plans. it just didn't go. it did not succeed. >> there was also a socialized system during world war ii, briefly, for maternity care, for soldiers' wives. the emergency maternity infant care act that was only temporary. >> this one near and dear to my heart. how do you think historical scholarship can be a useful tool to inform and give decisions to inform and help with the decision-making by policymakers. >> i think we have to look at history in order to have a honest conversation about what is happening now. a lot of the rhetoric that we hear around health reform debates today is not really based in accurate descriptions of the u.s. health care system or foreign health care system, s. so we have to understand what

are the definitions, what do we mean when we say universal health care, single-payer, things like that, and how do foreign countries actually do what they do? and so i think history, if i can brag about our profession, does a good job of providing accuracy in debates, so let's hope for that. >> history always helps. so if the key is performing private insurance, how can we go about doing that? [laughter] >> save the toughest for last. >> yes. well, the question of how you change a system when you have such a powerful economic investment. and how many people work in the private insurance industry. if we went, you know, tomorrow, to medicare for all as a single-payer government run system, how many people would be

out of a job? one of the arguments for the system that i described was the high-paying employment that had produced in all the people that delivered health care -- as you probably know, our administrative costs for how we deliver health care are the highest in the universe probably. we invest a huge part of our health care dollar in that management. we see it as ideologically superior because it is private , but we also like the economic benefit. changing that is really going to require an enormous brokering of economic interests so that the private insurance industry could accept the change. it is one reason i personally

think a more step-wise plan is likely to work because they are not going to go away, but maybe you want to make -- >> if we really want health care to be more affordable, it is difficult to see a role for private insurance as it now exists. the system besides ours that includes a role for private companies, most of them are actually nonprofit. private but nonprofit. so to take out the profit motive is obviously going to be a major way of reducing costs. it will reduce administrative costs and overhead. i think i am more leaning towards thinking that private insurance, it will be hard to find a solution through that entity, especially because they currently have too much say in our politics, and they may be a stakeholder but the main stakeholder in the health system is the people in this country who need health care, and that

is basically everybody. so i think that they should have left private insurance and less of a say in how we develop our system. >> one other characteristic of our european peers is they tolerate a much higher level of government regulation, of provider behavior, prices, who gets what care. and until we can accept that principle that the government needs to regulate, and i mean hard regulation, these problems are impossible, and we are clearly not to that place. >> change of consciousness. >> yes. >> time for one or two more. how have states' relationships with the health care system evolved over time? that's a question about state initiatives. >> great question. >> the health insurance debate began at the state level from the progressive era. it was almost entirely state

-proposed. because national insurance was seen as something that should not happen at the federal level. the role of the states was of course preserved in medicaid. and i know that there's a lot of hope for state experimentation that could help improve the health care system. but i think that the reality, historically, is that when devolved to a state responsibility, that really embeds a lot of inequity in the system because there's so much differential between states in terms of medicare benefits, in terms of who they cover. so i think the states certainly have a role to play, but they have also had a big role to play in preserving inequity in our system. >> on a more optimistic note, i think because of our federal

layer cake system, there is potential for states to try out different funding schemes and possibly show that a move towards, let's say a more european-style model, might be possible if you can make it work in massachusetts, if you can make it work in washington state, and that could possibly influence federal policy. that is an optimistic view. >> last question. what common themes have you observed throughout the history of health care regarding both what seems to be problematic and what creates progress? >> that is a great question. >> easy. >> go for it. >> go for it. >> the problems are easy. that is mostly what we talked about. the thing that keeps coming up over and over again is the distortion in the debates so that the debates that take place

politically are not -- they distort the reality of our health care systems so we have not had an honest discussion of how we actually deliver health care in this country, and that is what is necessary in order to change it. >> one of the lessons i have learned is the dangers of hyper-individualism, and the 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 that we do not have a sense of solidarity. this is what my dutch friends are like, what is wrong with your people? that hyper-individualism. we think it is so important to individualize everything and also to have competition. the worst thing you can do for the american character would be to relieve people of the fear that their health care is going to be covered.

that you would all start being lazy, unmotivated people. that is a lot of the ideology that drives this. it is a fear of welfare mentality taking over. and usually, your fear of welfarism is not going to be your family. it is that family across the street, or the family across the city 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? big question that bears discussion. >> along those lines, one example of success and something that has worked, it is not a top-down process. medicare is often attributed to the power of lyndon johnson and his negotiating prowess. he was amazing. but he was actually pushed by the civil rights movement and by senior citizens organizations to take the kind of stand he did on

medicare. so again, it goes back to the people organizing, and they are the ones who pushed the politicians to make change in the face of all the obstacles. >> some tough questions and excellent answers. thank you all for coming this morning. >> thank you. great questions. [applause] >> thank you to our presenters. [captions copyright national cable satellite corp. 2019] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org] >> this is american history tv. covering history c-span-style, with lectures, interviews and discussions with authors, historians and teachers. 48 hours, all weekend, every weekend, only on c-span3. >> manhattan college professor

adam aaronson talks about his research project examining the lives of slaves who escaped to canada, and what factors motivated them to stay or return to the united states during the reconstruction era. this interview was recorded at the organization of american historians annual meeting in philadelphia. >> the title of your paper here at the meeting, "crossing the border after the underground railroad, african north americans returning from canada." he people heard about t underground railroad, but why were slaves trying to escape to canada and how were they able to do that? >> the underground railroad was really a whole set of things together. it is roads, some rails, with people trying to get out of slavery and find ways to be safe. sometimes that was just in the northern states. sometimes that wn