Commentary - August 2009
Tex Med . 2009;105(8):59-60.
By John R. Pettigrove, MD
Franklin D. Roosevelt thought a single-payer health care system was too expensive during his early administrations, and by the 1940s, the country was preoccupied, and the subject did not come up again until after World War II.
Then Tommy Douglas, socialist premier of Saskatchewan, sponsored single-payer health care, starting a process that swept Canada and most of Europe. Social events in Europe created much consternation in the United States. Events swept the United States and stopped a similar initiative by the Truman administration in its tracks.
Lyndon Johnson tackled the problem again in 1965 and after extensive political debate, what we now call Medicare came into existence and has been with us since. My family doctor, Hilliard Denyer, MD, and most of his contemporaries thought Medicare would make most doctors rich but also that it would bankrupt the country. It seems they may have been right.
Why did they believe that? They knew what it took to care for the sick and elderly of this country. Most in their day were dedicated to the practice of medicine and, for them, money was a secondary consideration. It is hard to believe that today, but the practice of medicine was not as lucrative as it is today for some physicians.
Well, I remember my friend Jim Cook, now a dermatologist in Ashville, N.C., returning home upon the death of his father. His father was a general practitioner in rural Iowa. His dad had never retired and worked just days before his death. He had no money. He had educated several children, putting one of them through medical school. At the end, all he had were shoe boxes of IOUs from patients who could not or did not pay and a funeral at a small rural Presbyterian church packed with grateful patients and friends.
Since the passage of the first Medicare act, medical practice in this country has expanded, and health care is now one of the biggest items in expenditures and as a part of the gross national product. It is, as some might say, a redistribution of wealth. The only redistribution of wealth of similar magnitude that I can imagine in our times is the transfer of wealth from this country to the Middle East because of our energy demands. Until recently, no one said much about that.
Socialism, which arose from utopian dreamers - mostly evangelical Christians - during the 18th and 19th centuries, transiently flourished and subsequently died out during the 19th century. Only remnants of those communities exist today, such as isolated Mennonite and Amish communities.
That socialism started as a Christian ideal is hardly an accident. The New Testament, which so many conservative fundamental Christians claim to adhere to, is probably the most radical social document ever written.
Socialism failed for the same reason most social ideologies fail. People, after all, look after themselves first. The same problems have been the bane of capitalism and radical communism. No social or economic system can escape that problem. Economies go boom and bust. The Romans, as well as all other ancient and modern societies, experienced it.
What is socialism? A simple definition in most dictionaries calls it the redistribution of wealth from the means of production according to peoples' needs. In the Roman times, the means of production was slavery, as it was in the rural south before the Civil War. The redistribution went to a social minority according to their needs or wants. They were not accountable to anyone, but those who were socially more powerful, that is, commanded more armed men.
The industrial revolution ended the need for slavery and more than anything gave rise to free men and women who worked for wages. The industrial revolution brought about modern capitalism. It also brought an end to social serfdom throughout Europe and most of Asia. The last two countries to actually end serfdom in the West were Russia and Mexico. The last stand of egalitarian socialism was the idea of a radical German philosopher who believed that capitalism was inherently evil and should be destroyed. Karl Marx spawned the idea of radical communism, which in his mind was socialism taken to its logical extreme.
With the rise of communism, the world of ideas was at war with itself. Radical socialism and its alter ego, reactionary capitalism, became so extreme that in their purest forms they were hard to differentiate one from the other. By the outbreak of World War II in the 1930s, Communist Russia and the nationalist fascist countries of Western Europe had become radical or reactionary dictatorships. Much of the third world still finds itself in this situation today.
So there you have it, a brief economic and social history of the world.
Today, things don't seem much different; socialism and capitalism are still rival ideas. But the reality is really much different.
Technology has expanded dramatically during the last century, often because of scientific breakthroughs by some who were among other things social idealists and others who were striving capitalists in a free market society that was championed in America. The whole world thrived because of it, but that prosperity was not a linear progression. We had geometric growth periods and periods of traumatic declines. This is hardly surprising as nature is full of these examples of prosperity and famine.
Since American medicine proved to the world that technology and skills exist to treat the sick and give people better lives during the 20th century, the whole world has tried to emulate this system and provide similar care to their own peoples. Some were successful and others not so successful. During these times, new challenges have occurred in the form of technologic advances and new and threatening diseases not known before. As this process has continued, the cost of it all has risen. Many strategies have been tried to address this cost. In third world countries, the solution has been not to address them at all. The inequities of health and infectious disease in the third world and third world pockets such as inner-city ghettos in the United State have been largely ignored.
On the other hand, various countries have tried so-called socialist ideas. In some, it has been a failure and, in others, somewhat successful, but all have had problems. Socialist Sweden, for instance, may be the more successful, but even the most successful sneak a little capitalism into the system like a good cook seasons a secret recipe.
America has been blessed with success. That success was not handed over on a silver platter; rather, it was the product of generations of hard work and a booming and productive economy that went through good and bad times. Americans have had many things going for them. Among those are hard-working people, economic freedom with a level playing field, a relatively stable currency and bank system, and public education.
The American system and tradition are based on the 17th century puritan work ethic, access to education, and a public ideal of commitment to other people based upon the New Testament.
The Europeans who first came to this country were individualists who believed in hard work and the reward of the individual in this life or another. They had a strong sense of community. They lacked the tolerance of Jesus and perhaps that was their greatest weakness, but all immigrants since who have had a successful life have followed their example. It is because of that that the country has prospered.
Until perhaps the 1970s, the success of our health care system was based on the success and prosperity of our economy and egalitarian ideals of our community. This was a benign socialism that required each citizen to give according to his or her conscience and values.
Then technology overtook us. The cost to do the things we used to do for free became too great, and the system began to fail. New strategies came about. The first was Medicare, which became the template for the entire system. Doctors not only accepted it, but also embraced it.
Over the years, additional strategies were adopted to deal with increased cost. All these were based on modifications of the existing Medicare plan. We had voluntary assignment, then mandatory assignment, and by the 1980s we had DRGs. New strategies were designed. HMOs were developed to address corporate health costs, then IPOs and PPOs entered the scene
Medicare redistributed the wealth to the elderly and to the providers, i.e., doctors. Doctors went to the polls and voted conservative Republican, but supported and embraced Medicare wholeheartedly. As recently as last year, doctors, through the efforts of organized medicine, thwarted efforts by the Republicans in Congress to lower physician fees under the Budget Reconciliation Act. This act would have essentially lowered physician fees 10 percent a year for at least four years.
On the surface, all this social welfare would appear to be socialism. After all, the insurance industry is just an attempt by business to redistribute the wealth. Isn't that just a form of corporate welfare? Most physicians agree. Or do you really?
Dr. Pettigrove is an internal medicine specialist in Corpus Christi and a member of the Texas Medicine Editorial Board.
The views expressed in this commentary are those of the author and do not necessarily reflect the views of Texas Medicine or the Texas Medical Association.
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