Chapter 5: The Coming of the Corporation

This final chapter looks on to the future of American medicine. The book was published in the 1980's, so Starr makes predictions about what the future from that time (mainly the 1980's and '90's) will hold.

More Physicians, More Competition, More Problems?
The first Prediction Starr focuses on is a doctor surplus and competition. In the 1970's, the U.S. increased number of medical schools and funding for medicine in general through different mechanisms, two of which are Medicare and Medicaid. Starr states that the medical services in the 1980's will become "a zero-sum game," in which "New physicians may no longer be able to introduce an additional layer of specialized services into a community on top of what other practitioners offer." Thus, there will be a great increase in competition and other tension between physicians.

A second prediction pertaining to doctors is the possibility of tensions arising between hospitals and physicians. Starr states that as competition increases, hospitals will venture into aspects of medicine usually dominated by private practitioners (ambulatory care, etc.) and vice versa will occur with physicians. This will lead to a "collision course" leading to increased tension. Various tensions could result

• hospitals will need to increase medical staff, who will begin competing for leadership positions, etc.
• hospitals may need to find other ways to provide care for the poor if funding for medical ventures are cut back

Despite these individual tension predictions, the main problem Starr predicts is that "Throughout the medical world, the rising numbers of physicians mean renewed conflict and fragmentation."

Corporate Medicine
The next major prediction is that corporate influence will expand exponentially into the field of medicine. Medicine became much more profitable in the 1970's because of the creation of Medicaid, Medicare, etc. Different investors recognized the perks physicians (and other medical professionals) were enjoying, and have begun to find their own ways of entering medicine. This new corporate influence will lead to higher levels of integrated control by corporations. Starr predicts 5 different types of integrated control changes:

1. Change in Type of Ownership and Control
2. Horizontal Integration
3. Diversification and Corporate Restructuring
4. Vertical Integration
5. Industry Concentration

One major consequence of corporate influence in medicine will be consolidation of the hospital system. Earlier in the 20th century, lone-standing voluntary hospitals predominated the hospital system. Into the 1970's, this is all changing as "multihospital systems" popularize. Profit-making hospital chains are sprouting up across the nation. Additionally, some hospital chains have even expanded beyond American boundaries and established their own facilities in other countries, including England, Venezuela, and Singapore.

These multihospital chains have led to the introduction of "managerial capitalizm" into American medicine. There is now strong central managements that strive to control hospital chains. Management can be controlled by either a corporoate board or corporate management, depending on whether it is a nonprofit or for-profit hospital.

Ironically, in the 1970's and 1980's, researchers did not know if multihospital systems were actually more economical than lone standing hospitals. While it may seem that multihospitals will ead to more efficient care and cheaper services, different studies proved this assumption may not prove true. However, multihospital chains did gain popularity because it provided power to hospital chains to bargain and compete with impeding political and corporate powers that now strived to gain influence over hospitals. As Starr states, "[multihospital systems] may answer demands for poewr, profit, and institutional survival that freestanding hospitals cannot satisfy. In recent years, closer regulation, tighter reimbursement, and higher interest rates seem to have stimulated the process of consolidation."

Increase in multihospital systems pose several problems. One problem is that it takes power away form local communities as national corporations gain power over various hospitals. Second, these for-profit organizations may not provide as many services to the poor who cannot pay for their care.

Corporate Influence has also led to diversification amongs hospitals. Voluntary hospitals are starting legal arrangements that will allow them to pursue additional business ventures to help generate revenues; They are becoming "polycorporate."As stated by Starr, "Under the umbrella of this new polycorporate enterprise, the tax-exempt nonprofit hospital can operate taxable, for-profit businesses." This corporate reorganization has caused many changes in hospitals. One change is "unbundling," one part of a hospital becomes its own corporation and pursues its own business ventures. In contrast, some hospitals may contract out its operations to independent organizations.

The major change corporation of medicine has brought about is the "break down in voluntarism." In the past, medicine was driven by voluntary motivations. In the 1970's and 1980's, this changed completely as all aspects of medicine began to take on for-profit goals.

Business Influence
Finally, the corporation of medicine will most likely shift who controls decision making within medicine. In the 1980's, individuals in the field of business entered medicine to help control "costs by the private sector." Specifically, different coaalitions formed to help regulate costs. This significied the "transfer of functions from federally-sponsored organizations to business-sponsored organizations and the states" which strived to control medicine.

Before the latter part of the 20th century, physicians and medical professionals maintained their autonomy through several means. However, in this new day and age, they have lost their competetive appeal. Before, physicians were the sole controlling leaders of the medical field -- they dispensed medical care, maintained close relationships to patients, etc. But, this competetive zeal has "eroded. Specialization has diminished the scope of relations between doctors and patients. [...]Employers and the government have become critical intermediaries in the system because of their financial role."

Additionally, medical professionals, themselves, are no longer as opposed to third party mediation. Many physicians now prefer to enter group practices and participate in HMOs. Others applaud the entry of corporate influence into medicine. Even the AMA has recognized the shift in physician preference and do not explicitly criticize corporate influence over medicine.

However, despite these changes, physicians will still have to face some loss of autonomy in the future. As corporate influence increases, there will be more restraints placed on physicians. There will be:

• More scrutiny to determine if physicians are performing their work well
• They may lose the ability to decide who holds managerial positions
• The locus of control of the organizations where physicians work will become heteronomous (control will come from outside the "immediate organization")
• Finally, they will have to work within rules and standards set up the corporations in control

These changes will lead to both social and political changes. First, socially, the medical field will change drastically as business people begin to infiltrate the "ranks." "Everywhere one sees the growth of a kind of marketing mentality in health care. And, indeed, business graduates are displaced [medical personnel]." Second, these changes will have a political impact. "As an interest group, the new health care conglomerates will obviously be a powerful force."

Thus, Starr predicts tremendous change in medicine initiated by the entrance of corporate influence and control.

What has really happened?
It was very interesting to read what Starr thought would happen after the 1970's. However, as we all know now, many other changes have also occurred. I researched some of the changes I've seen in the last few years. Instead of going into each one in detail, they're listed below. If I found any articles pertaining to the issue, I also have them listed --

• The increase in technology and research has led to even more specialization.

I found an interesting site about Evolutionary Biology in the 21st century and it's implications on modern medicine. This field allows advances in chemotherapy treatments, prolonging chemical compound life, and even pathogen tracking.

• Tension and competition between doctors has increased increase.
• A need for medical curriculum to adopt to constant changes arising in modern medicine.

I found a study summarized in the article "Physicians for the 21st Century" that looked at how medical curriculum has adopted to the changes in modern medicine. In the end, the researchers concluded that while some changes had been made to keep up with modern findings, more changes should be made so that medical students are adequately prepared to work in the 21st century.

• Patients still maintain the right to "control" their own health care (signified, in part, by the rise in malpractice suits in the early 2000's).

Several other changes have also occurred that Starr could not have predicted. Mainly, as I've discussed many times throughout this blog, is the changes that the potential Obama-backed health care reform will bring in the next few years. Like Starr states at the end of his book, "Images of the future are usually only caricatures of the present." Time can only tell what the future will hold for American medicine. The best we can do is keep up to date with ongoing changes.

Chapter 4: End of Mandate

This Chapter goes over the history of American medicine in the 1970's. Starr states that there were three different political "Revelations" that occurred through this decade. The following will summarize key points of the 1970's by way of these three revelations.

The First Revelation: Crisis
As a result of the expansion and increase in the medical field throughout the 1960's, the 1970
s was faced with a need to cap ongoing expansion that was now resulting in high costs and depletion of resources. Politicians in the early 1970's recognized these problems and openly stated that American medicine was now in a state of "crisis." A possibility for national health insurance reappeared as both conservatives and liberals began to believe that such a plan could resolve the "crisis of money."

There were several reasons behind rising health costs

• government share of health costs had increased
• rising health costs of Medicare and Medicaid -- as research& technology increased, more money was needed to provide the "best" services to patients, which they had come to expect
  
• fee for service reimbursements allowed doctors and hospitals to charge high prices for services, requiring employers to pick up the difference for their workers and the government for the poor

These problems are summarized by Starr, "Patients want the best medical services available. Providers know that the more services they give and the more complex the services are, the more they earn and the more they are likely to please their clients." This idea led to overuse of services, over prescribing of services, etc. that led to unneeded costs. Furthermore, over expansion of services was not the only problem that stemmed from this ideology. "The incentives that favored hospital care promoted neglect of ambulatory and preventive health services." Furthermore, there was less money available for the public sector (voluntary hospitals, etc.)

Rising costs led many to be wary of physicians and other medical professionals. There was a sort of "revolt' against medical professionals. Major changes occurred:

• Patient's rights were created via the the Patient's Bill of Rights and the individual creation of other rights "in health care," such as right to refuse treatment, were created.
• Women's rebellion against modern medical professionals.
  
• The most radical change was when women began to take medicine "back into their own hands" -- alternative abortion clinics were started, midwives popularized, etc
• Return of Alternative Medicine

And, most importantly, for the first time, the doctor was now seen as a "villain."

This new revolutionary thought that went doubted medical professionals' credibility along with the recognition that high medical costs needed to be tamed led to a dire need for government intervention.

The beginning of the 1970's was also characterized by a series of legislation geared towards regulating medical control. The main things created were: government HMO's, National Health Planning, and PSRO's. There were all agencies created to control costs.

Another major try to regulate medicine were two different plans for a national insurance plan. One was created by President Nixon and his administration and one was backed by Senator Kennedy. However, neither actually came to be.

The Second Revelation: Therapeutic Nihilism
The series of legislation halted in the mid 1970's when the U.S. was faced with recession and inflation. The U.S. government found itself herded in by the multitude of legislation it had just passed in just four short years. Despite the legislation, which was passed in part to help control costs, the recession disabled the government from passing any further reforms in fear of depleting national funds. Additionally, government officials realized that further legislation would continue to eat up more and more time. Not only does the legislation, itself, take an "inexorable" amount of time to bring into reality, but there was also a growing pattern of litigation following any government legislation. In short, the U.S. no longer had the time or money to continue bringing about new legislation as it had in the first half of the 1970's.

The government agreed to bring about an HMO project in hopes of controlling costs as an experiment. In the final version of the legislation, the new plan called for "low subsidies and high requirements" of the HMO's. These requirements proved damaging. Employers were hesitant to use HMO plans because they were "uncertai[n] about which plans would qualify under the statutes." Also, "neither the capital nor the management skill swere readily available" to put HMO plans into place. Thus, in the end, this plan failed, just like other health care reform at the time.

These failures led to severe down of the medical system in the U.S. As Starr states, "the 19th century doctrine of therapeutic nihilism-- that existing drugs and therapies were useless-- was revived in a new form. Now the net effectiveness of the medical system as a whole was called into question." The American public saw that an inordinate amount of money was being spent on medicine -- research, legislation, etc. -- but little differences were made. There were now doubts about whether we really need medicine. Many stated that, while modern medicine had been good before this time, the population was now so healthy that medicine would no longer effect mortality rates. Critics now wanted to put "greater emphasis on changing unhealthy individual behavior."

Thus, there was a severe shift in thinking where, in general, Americans believed there was now a need for cost control. For the first time, both Right and left wing politicians agreed with this notion. Once again, there were different proposals for a national health insurance plan (one from President Carter and another from Senator Kennedy); however, both proposals were unsuccessful, being deemed implausible and/or too expensive.

Fortunately, some of the programs set up in the early 1970's, now proved fruitful in the late 1970's. The new planning programs that had been put in place were helping cost control. The HMO's began to do well; although they were not as successful as the Nixon administration had hoped. "Reform had succeeded in many original aims to improve access to health services." However, the tides were still turning and politicians were "on the defensive, while health care providers denounced the excesses , duplication, and irrationality of government." The industry was now "criticizing the inefficiency of reform."

Despite the heightened recognition about "the irrationality of [the health care] system, the financial insecurity it created, and its effects on the use of primary and preventive health services," no concrete health care reform or solutions were successfully put into effect in the late 1970's.

The Third Revelation
By the late 1970's, there was a final shift in thought -- "the problems of health care in America could be cured by relying on competition and incentives, if only the government's role was reduced to a minimum." When Reagan took office, he wanted to immediately "abolish the HSAs and PSROs, to consolidate federal health programs, and to "cap federal support for Medicaid." Despite this ambitious plan, there was still opposition for physicians and hospitals. These parties welcomed less regulation from the government, but did not want to see cutbacks on their federal funding. Due to such opposition, the Reagan administration backed away from their "competetive approach."

In the end...
Thus, we see that there were three clear revelations throughout the 1970's. In the beginning, there was a need to quickly slow down progression of medicine that had been so popularin the 1960's. Then, recession and inflation in the mid 1970's led to a halt of legislation that ensued earlier in the decade. Finally, towards the end of the decade, America finally realised the need for severe cost containment of medicine. However, no legislation was able to be passed due to impeding factors.

Another general theme throughout the decade was a clear distrust for medicine. It began as individuals began to question doctor's and their motivation for working. In the beginning of the decade, patients insisted on finding ways to "protect" themselves from doctors, which gave way to the "Patient's Bill of Rights" and other rights in health care. After this, there came a general distrust for the entire field of medicine. Americans questioned whether we really needed medicine to protect our health anymore. I believe this embellished way of thinking stemmed from a momentary panic when Americans were struck by the large amounts of money the medical field was eating away. Finally, perhaps there was a return to a somewhat more clear-minded way of thinking in the late 1970's, as government officials began to focus on how to contain exceeding medical costs.

Either way, it is interesting to see what happened when, for perhaps the first time in American history, doctors and medical professions were not hailed as national heroes. Medicine was put on the defensive. Past strategies of simply campaigning against or sabotaging legislation or movements that impeded their self "autonomy" did not work anymore. Doctors were now, or so it seems, willing to compromise as they too noted the excess present in medicine.

Another interesting first was how, in just a short time, the government used three different strategies to control medical costs. I don't think I've seen such hurried strategies in this entire book. Three different presidential administrations (Nixon, Carter, and Reagan) all had different ideas on how to control excess in medicine and each at least tried to pass its own legislation early in the presidency.

Obama and 2009
My final point brings me to the Obama administration. Like the 1970's, this presidential administration, too, is working to quickly pass health care reform. One of the main reasons is to curb unprecedented costs in medicine. I am very interested to see how this reform will turn out.

Chapter 3: The Liberal Years

This chapter covers a period of incredible growth within the field of medicine from Post-WW2 through the 1960's. There were two major waves of expansion, and I will cover each wave (and issues surrounding each individual wave) separately.

However, both waves of success did follow a similar pattern. As Starr states, "after pursuing growth and redistribution without reorganization, [Americans] accepted the need for reorganization to stop growth." Initially, both waves began with an emphasis on uncapped growth that led to shortages and bad distribution of resources in many areas. In the end, all expansion had to be controlled and leveled off, so that the different problems that arose could be tended to.

Post WW2: Unprecedented Growth
The U.S. established itself as the world's leading economic power after WW2. While many European countries were utterly devastated by the war, the U.S. enjoyed both economic and scientific advances during this period. Major key discoveries -- including a synthetic strain to battle malaria, penicillin, and even the creation of the atom bomb -- allowed America to establish itself as the leader in scientific research. Thus, research became a priority in the 1930's. Such key organizations, like the NIH, were created to propagate research. The American public also jumped on board as different groups of people started to rally behind different research "causes." Various lobbyist groups were created so that supporters could bring attention to various research fields. Different institutions utilized the public's interest in research to gain funding. The NIH began a "categorical" approach -- they established various institutes that emphasized a certain disease, which supporters could give money to.

While the government created organizations, like the NIH to provide funds and grants for research, the scientific community still retained control over research. "The approval of grant applications as well as basic policy issues rested with panels of nongovernmental scientists." This illustrates how the professionals maintained sovereignty during research expansion.

Another change that occurred in the post-war period was that many diseases that had been major concerns of scientific research in the past, such as polio, had now been cured. This change allowed Americans to shift what the focus of medicine and health was. Mental health and psychiatry was one one of the fields that now became a "mainstream" concern. Many factors contributed to this change. First, the military was changing its use of psychiatry from a "descriptive psychiatry" that simply labeled patients as mentally unwell and turned them away, to a "dynamic psychiatry," that worked to help mentally unwell patients. Second, people were now aware of the neglect and repression that occurred in mental institutions. Thus, mental institutions lost popularity, giving way to the need for a new way to take care of mental health patients. Ultimately, medical professionals began to treat mental health patients in a completely different way. Instead of simply dumping mental health patients in institutions, as had been done in the past, there was now an emphasis on treating patients over time.

A third change that occurred during this period was an increase in hospital use. There was a large campaign to increase construction of hospitals. This campaign was widely supported because it would create many jobs that were much needed (i.e. for returning veterans). As the sheer number of hospital beds increased, so did the number of patients hospitals could tend to. The Hill-Burton allowed for a majority of states to begin construction of hospitals. While federal funds supported this program, states were given the authority to determine how the funds were allocated, etc. Originally, these "arrangements were meant to minimize 'politics.'"

There were many problems that arose from this arrangement. Two examples of the problems that arose are that most of the funds went to middle class families and some hospitals discriminated against African Americans.

A fourth post-war campaign also led to the expansion of the VA.

Similarities of the Four Campaigns
Thus, there were four main changes that occurred in the post-WW2 period: medical research increase, hospital construction, increase in mental health, and VA. Each program showed "a common pattern in respecting the sovereignty of the medical profession and local medical institutions. While the government was used to help aid these projects, its power to intervene was severely controlled.

• NIH grants had to be approved by a panel of non-government members
• mental health program established under the NIH relied on peer evaluation
• "Dean's Committees," not the government, were given the power to appoint physicians in the VA system
• The Hill Burton program allowed the federal government limited control in determining how grants and funds were allocated

Changes the First Wave Brought About
The first major change that occurred was that medical schools grew exponentially. As researchers gained more money, so did affiliated medical schools. Thus, they grew to become "complex organizations" that encompassed research facilities, hospitals, etc. This expansion had a bad effect on local physicians (sometimes called LMD's). As medical schools grew, they desired better, more accredited physicians to serve as faculty and staff. Consequently, LMD's were oftentimes displaced out of their jobs. This led to anger and tension between local doctors and medical schools.

Clinical and Science departments in medical schools were also growing apart. As research increased, so did the integrity of medical specialties. Knowledge about medical specialties were increasing, allowing clinical and science departments to become very distinct. Furthermore, specialists began gaining mroe money -- leading to specialty doctors to gain more prestige in the hospital.

The increase in knowledge also led to chance in medical school curriculum. Med students were now expected to learn an insane amoun of knowledge within their four year degree program. The first two years, which consists of classes, was especially hard on students. However, the last two years were more easily changed. Many schools adopted program that separated clinical rotations into specialties to better organize these last two years. Also, some schools included "elective" periods, which allowed students to choose what speciality they wanted ot rotate in.

Interest in specialties also increased at this time. Students saw that specialists were more respected and making more money at this time; so, more med students began pursuing specialty fields. This revelation was good for hospitals. Med students had to now spend more time working after their one year internships to learn about specialties. These students provided hospitals with an increased work force to tend to the increasing number of patients. One problem that did arise from this increase in students was a need to certify specialties. Eventually, the AMA created the "Advisory Board for Medical Specialties" that provided boards for students to pass tobecome specialists. A problem that did persist was a need to control the number of specialists.

In the end, the number of general practitioners decreased and specialists increased. There was now a need to help alleviate this discrepancy.

The last change that occurred via these post-war changes was a distribution of power within physicians. As medical research and facilities increased, so did the need for doctors. Thus, medical institutions started recruiting physicians from abroad. Furthermore, some physicians began working with medical schools a sresearchers while some stayed back as private practitioners. Eventually, three different groups of physicians were created:

• First group: physicians who worked with medical schools and hospitals, oftentimes were faculty who focused on research and training
• Second group: Private practitioners; while they were not affiliated with medical schools, they were still very economically successful.
  
• Third group: doctors who worked in rural or inner-city areas; oftentimes were physicians brought in from other countries
  

The Second Wave: 1960's
Changes that occurred in the 1960's were mrore concerned with reform. There was now a widespread belief that the government was "overemphasizing" hospital construction. Many believed that there should be an emphasis on centers that could provided comprehensive are instead. The Kennedy Administration took up this idea and began backing "community centers," which would provide several services. This idea was very different from the HIll-Burton -- instead of giving power to individuals and the staes, thois idea would link the federal government directly with ocmmunities.

The Kennedy Administration had two major contribution to chanes in the '60's. First, Kennedy initiated a tax cut that led to major economic growth in the '60's. Second, he initiated an antipoverty program. At first, this antipoverty plan was more focused on "community action and education" to help the poor take care of themselves. It later encompassed medical care for the poor.

Different Forces at Play
There were different forces that led to social change in the 1960's.

• Self interest dictated that there was now a need for social reform
• The labor movement wanted a national insurance plan to help medical institutions "build additional capacity"
• Many "radical" groups wanted the creation of "comprehensive centers" instead of hospitals
• Medicare became a national issue

Indeed, the elderly was a main concern for Americans in the 1960's. The Kerr-Mills program was created in 1960 to "extend federal support for welfare medicine programs in the states." Initially, this program provided some additional benefits to Social Security for the elderly.

Of course, different groups had their own views on what type of insurance or health care plan would best suit the elderly. Republicans, Democrats, and the AMA had varying opinions. A compromise was created by Representative Mills that created a "three layer" program that brought together all three views. This threepart plan was signed by Johnson in 1965 and brought Medicare into existence. Medicare was quickly accepted and proved to work well for the elderly.

Medicaid was a different story. Many people did not believe medicaid would work out well. Instead, some supported "health center progrms [...] to create a one stop facility in low-income communities." In addition to providing care, these centers would also teach the poor how to take care of themselves. In the end, these centers did not expand significantly. And, instead, Medicaid became the major way to provide health care to the poor.

The Second Wave... What was it?
Starr states that these changes represented a second stage of medical care expansion in the US. The first tage had been the post-WW2 changes we have already gone over. The second stage were the "social programs of the 1960s [that] were aimed specifically at reducing exclusion from medical care of the poor and the aged, who were marginal to the core sectors of the economy where health insurance was available as a fringe benefit."

Ending Comments
So, we see there were two distinct waves of expansion of medical services. I believe the first wave was a direct result of the success the U.S. enjoyed during WW2. Not only did the U.S. become an economic power following the war, but AMericans were also shown the sheer advantages science research can bring about. Thus, there was a hurried and uncapped rush to propagate scientific research so that America could reep the benefits. As a consequence, medical schools and medical professionals enjoyed increases in power and resources due to the flood of funding that was channeled to research.

However, this expansion did not come without it's own problems. The increase in hospitals led to a need for more hospital staff. The increase in specialists led to a disparity between GP's and specialty physicians. Also, there was almost no attention given whether all groups of the population were given adequate health care at this time.

Therefore, by the 1960's, there was a need for radical political and social change concerning how medical care was provided. This led to the creation of the Medicare and Medicaid programs.

Chapter 2: The Triumph of Accommodation

In this chapter, we will trace the transformation of Private insurance into the mid 20th century.

• To understand the different factors that effect the infrastructure and consequences of such a system one has to understand the theory of "moral hazard." Insureres need "any hazard insured against and the llosses arising from it to be unambiguous when they occur and beyond the control of the insured." If they are ambiguous, insurers cannot figure out how much the costs of the illness cost. However, in a private insurance companies many parties will effect the costs of services and not all illness or sickness will be due to a "well-defined condition."

There are three types of benefits insurance companies provide:

1. Indemnity benefits: reimburses the subscriber for medical expenses, but not usually all fo the expenses
2. Service benefits: guarantees payment directly to physician or hospital (will usually cover all expenses)
3. Direct Services: the provision of health services to the subscriber by the organization receiving prepayment

Each plan will vary on complexity of relationship between the three involved parties (physician/hospitals, subscriber, and insurer) and in what limitations on reimbursements, services, etc.

• Indemnity plans: usually transactions occur directly between the subcriber and insurer
• Dervice-benefit plans: physician/hospital will file for a reimbursement; so this plan usually involves some sort of negotiation
• direct services: doctors and hospitals are integrated into the same organization that enrolls subscribers; so, the organization control various aspects of the process from quality of services, to reimbursements, etc.
  

Thus, the type of plan and the degree of involvement eit requires will determine how far providers will go to control their own financial risk. Since direct service plans already have control over their providers, they don't have as much need to control them. On the other hand, since Indemnity plans have the least amount of interaction between providres and subscribers, they must find more ways to control or limit their liabilities.

The creation of Hospital Insurance
The idea of hospital insurance started at Baylor University, when the school provided a group of teachers with hospital coverage for up to 21 days for $6/year. Such plans popularized and soon after th eonset of the Depression, hospitals began providing coverage also. Unlike insurance companies, these plans started "with hardly any starting capital." However, this was ok, because "member hospitals agree[d] t provide service regardless of the remuneration they would receive."

In 1934, a New York law allowed hospital insurance plans to be exempt for regular insurance regulations. However, this law allowed hospital insurance plans to be reviewed by the insurance department. This law also gave hospitals a power over the plans by providing that a "majority of the directors of the plan be administrators or trustees of the hospital that contracted to provide service." This provision allowed the precendent for voluntary hospitals to have long-term control over the Blue Cross system.

A problem with the original single hospital insurance plans was that it promoted competition between hospitals that oftentimes got in the way of providing good health care. The American Hospital Association (AHA) recognized this problem and soon began promoting group hospitalization. The AHA created the Committee for Hospital Service, which put out a set of principles for Blue Cross plans, that required n ocompetition between them. They set up defined terrirtories for hospitals and required states now be in charge of supervising the plans. However, it still included a provision to ensure hospital heads would still be the main directors of the insurance plans. By 1939, 25 other states had passed acts that created hospital service plans.

While the hospital insurance plans had initial advantages over their competitors (insurance companies), insurance companies still had more financial resouraces and their "long-established relations with employers." Thus, despite efforts by the AHA, insurance companies had almost 8x the subscribers as hospital insurance plans in 1940.

Physician's Reaction
The AMA was initially against hospital insurance and wanted there to be a separation for medical and hospital care. However, a 1936 survey showed a majority of physicans were for hospital insurance because if patients could have their hospital care covered, they were more likely to pay their medical bills.

In the early 1930's the AMA put out a set of ten principles they used to spell out their prerogatives. In short, these principles stated that there should be no third party intervention in payment for health services, physicians be allowed to charge the same prices as their colleagues, and maintain a relationship directly with their patients without third party intervention. As Starr states, these principles basically said that "all health insurance plans accept the private physicians' monopoly control of the medical market and complete authority over all aspects of medical institutions."

However, there were already many agreements that went against these "no third party intervention" principles. The first conscious attempt to reorganize medical care into a prepaid, comprehensive basis occurred in 1929 with the cooperative movement. The "medical cooperatives [...] emphasied four principles: group practice, prepayment, preventive medicine, and--uniquely -- consumer participation." This first cooperative health plan was created in Oklahoma by a physician named Michael Shadid. Shadid first approached local doctors to begin the program, but they were adamantly against it. He then went to local farmers who helped back the plan. Soon, the medical professinals in the area launched a campaign against this plan. Despite their efforts, Shadid obtained legal support and was soon able to spread the program throughout Oklahoma and into Texas.

The federal government even started a rural health cooperative plan. Shadid supported cooperatives by stating "the only successful alternative to compulsory health insurance." He asked the government not to intervene in providing coverage, but instead to "subsidize the poor" so they could enroll in the programs. However, Shadid was not against medical authority. He just allowed consumers to have more authority than the AMA approved.

The AMA vehemently disagreed with cooperatives because it controlled the physician authority over medical care; specifically, these plans "subjected doctors' incomes and working conditions to direct control by their clients." Soon, the AMA launched a full out campaign to sabotage the Group Health Association. In December 1938, the Justice Department "secured an indictiment agaisnt" medical organizations that were conspiring to destroy the GHA. However, by the time the indictment was in full effect, medical professions had already successfully stopped several cooperatives from forming. And, by 1939, the medical societies had gotten state intervention to ensure medical professionals could have control over prepayment plans. Several states passed laws that banned consumer-run insurance plans and other states required "all plans to allow free choice of physician."

Ultimately, medical professionals now enjoyed a monopoly over insurance plans.

Blue Shield vs. Blue Cross Plans
These plans had severa differences. Blue Cross was closer to prepayment plans and Blue shield was insurance. Blue Cross plans maintained that they serve dthe entire community and presented themselves as progressive. While Blue shiled aimed to prevent a government program form being adopted.

And the Unions Enter...
Collective Bargaining and Social Security are noted by Starr as being the two "great institutional legacies of the New Deal in social policy." While social security left out benefits for employees, the Wagner Act allowed for collective bargaining, therefore giving groups of people the opportunity to negotiate benefits from their employers. However, employees did not take advantage of collective bargaining until after WW2. Until this point, employee benefit plans were "management controlled," benefiting the needs or priorities of the management.

However, after the war in 1948, unions began focusing on getting better health insurance. The Tart-Hartley Act resored Wagner's ambiguous phrase "wages and conditions of employment," giving unions the legal backing to have a say in health care. By the 1950's, unions were negotiation for almost 1/4 od health insurance in America. Unions were insanely successful in their negotations; in fact, by 1950, employers ewre paying for almost 37% of health care costs for workers.

There were disagreements between management and unions on which type of insurance to use. Unions preferred Blue Cross and management preferred private insurance carriers. There were also differences in what differences collective bargaining led to dependign on whether unions were negotiating with businesses with few or many employers. Also, different types of unions also wanted different benefits (i.e. progressive unions wanted prepayment approach).

Despite these differences, it is clear the Unions successfully used collective bargaining to obtain employee benefits in the Post-WW2 period.

United Mine Workers of America
The next section follows the history of the UMWA and four strikes that led to union control of medical care. In summary, a lack of adequate medical care provided to miner workers led the UMWA to have 3 strikes over 4 years that would transform union control over medical care in the coal industry. The first strike occurred in 1946 when mine operators refused to provide 5 cents for "every ton of coal produced to fund a welfare fund to be operated by the UMWA. The government was forced to come in and takeover mines to stop a national economic crisis and, soon, a deal was struck with the union leaders. However, break down in relations would lead to two consecutive strikes in the years following.

After these strikes, miners had obtained a welfare fund that worked as an "open-panel, service-benefit program." Later, in the 1950's, the union began controlling and monitorying how doctors were treating their union members and their dependents. By the end of the 1950's, physicians or doctors had to be on a pre-approved list to even be paid by the fund. Furthermore, the fund could impose control on differnt insurance companies too. Ultimately, "the programs radically transformed the minors from a group that was virtually powerless in health care into a major force in controlling the cost and quality of medical services in coal-mining regions."

Other unions were also able to gain get some control over the type of medical care they were given. Many recognized that different parties (physician/hospitals & insurance companies) were over-charging for services. They found three different ways to control over charging -- bargain prices among different insurance companies, monitor cost/quality directly, or get physicians to accept a fee schedule.

Prepaid Group Insurance
Prepaid group insurance was a popular alternative because it's coverage was comprehensive and offered high quality services (mostly because group practices offered advantages like easier consultation, better preventive care, etc.).

Kaiser was one of the first prepaid group practices. Although, at first Kaiser and other group practices had a hard time getting employees to enroll in their programs. To alleviate this problem, they allowed their insurance plans to be offered as a "multiple-choice" program, in which employees can decide which type of plan they want. Soon, dual choice became very popular, in which employees could choose Kaiser or another program.

Physicians were adamantly against prepaid group plans. First, these plans were attracting middle income patients, that usually provided the most money to physicians. Traditional ways of campaigning against insurance plans did not work this time around. Physicians resorted to individual plans of discrediting Kaiser and other group plans; for example, physician's families handed out literature against Kaiser on their own. Some doctors even offered to take cheaper fees. In the end, Physicians were unsuccessful and enrollment in Kaiser plans continued to grow.

Chapter 1: The Mirage of Reform

This and subsequent posts will follow the second half of this book.

The Mirage of Reform covers the conception of health insurance. There were three major waves of support for national health insurance. Unfortunately, all three attempts failed to turn national health insurance into a reality.

The first widespread support for national health insurance came in the early 20th century:

The first interesting point comes from the first section, where Starr states the following: "So, contrary to the modern view of the welfare state as "liberal" reform (in the current American sense), social insurance was generally introduced first in authoritarian and paternalistic regimes." (p.239). I find this interesting because in the present day, mostly liberals (or democrats to a certain extent) favor a national health insurance plan. However, in its beginnings, health insurance was not viewed in the same light. It represented an intrusion of the government into health care. Before health insurance, health care was given to the poor through almshouses, etc. that provided free services to all who needed them. In contrast,health insurance was created, "as a means of maintaining the incomes, productive effort, and political allegiance of the working class." Therefore, it can be seen as a government intervention that quite apparently "abolished the traditional system of poor relief," such as health care provided in almshouses, that had been commonplace until this time.

Health insurance was first backed by the Socialist party in 1904. The American Association for Labor Legislation (AALL) was the major association that backed health insurance. The association gained the suppport of the Progressive Party; unfortunately, the party's decline after the election of 1912 hindered legislation in support of national health insurance to be passed. However, the issue did gain some widespread support throughout the country at this time. Some points of tension did exist, which included the following: 1. public health supporters thought that "preventive medicine ought to be the overriding concern;" 2. how physicians should be paid for their services; 3. physicians worried that they would lose their autonomy.

More trouble arose when the American Federation of Labor publicly opposed health insurance. Leaders of the association believed that "workers could rely [...] on their own economic power, not the state, to obtain higher wages and benefits." Many believed that "compulsory health insurance was contrary to their interests. {...} [and that] voluntary insurance would be the 'higher and better method."

In the end, support for health insurance waned and the legislation fell through. Two key reasons are noted by Starr: first, the growing opposition from doctors; and, second, America entering WW1, which "diverted attention from social reform, channeled the enthusiasm for doing good into a crusade abroad, and divided the old nationalist Progressives[...]." Along with these two developments, Starr also states that conflicting views of the three main parties (physicians, labor, and businesses) and a lack of a national leader to back the program also contributed to the collapse of health insurance reform in America.

Second, around the time of the Depression & Roosevelt Administration:
When the topic of health insurance reappeared in the '20's, the main focus shifted from solving "wage loss of sickness" to "financing and expanding access to medical care." This shift occurred because politicians became aware of rising medical costs as a major problem, which could be attributed to the "complete transformation of hospital care at the turn of the century." Also, the rising power of physicians and "gradual depletions of physicians in rural areas" also effected health insurance issues at this time.

However, health insurance was pushed to the sidelines when Social Security became apolitical priority during the times of the Depression. Many believed that aiding the aging population would help alleviate some of the economic burden of the Depression. While in European countries, support for compensation for the elderly, and even worker's compensation, "naturally" led to support for widespread health insurance, the contrary occurred in the U.S. Although some political members, including members of the Committee of Economic Security, were for health insurance, leaders of the social security movement believed that including "any health insurance amendment would 'spell defeat for the entire bill.'" However, "the ommisison of health insurance from the Social Security Act was by no means the act's only conservative feature. It relied on regressive tax and gave no coverage to some of the very poor [and], the standards for unemployment insurance were weak."However, the bill did extend the role of public health, like giving state funds for maternal & infant care and general public health work.

The Depression seemed to be the perfect circumstances in which support for a national health insurance policy resurfaced. Many people were unable to pay for health services, so, for the first time, physicians went to welfare departments and demanded they pay for free services. In 1935, the "Resettlement Administration began to set up and subsidize cooperative medical prepayment plans among the poor farmers it was assisting." [...] In effect, this was gveronment-sponsored health insurance. Health insurance "promised to stimulate use of physicians' services and help patients pay their bills." To counteract this economic problem, the AMA tried to restrict the number of physicians in hopes of increasing their incomes. Their efforts proved fruitless. So, by the 2930's, the AMA stopped such efforts, and "instead of opposing all insurance [...], it began to define terms on which voluntary programs might be acceptable." However, they never supported the actual carrying out of these terms. These actions were not favored by a majority of the AMA members. It is said that only an "active minority" carried out such actions. Few tried to oppose the AMA. One significant opposition came from the "Committe of Physicians for the Improvement of Medicine."

Despite the AMA's opposition, Roosevelt's administration did support a possibilie national health insurance program. In 1938, a conference was even heled to discuss the "nation's health needs" for such a program convened. However, in the end, a national health insurance policy was excluded from the New Deal. Starr states many possible reasons for this exclusion. First, only about a "third of the population" was definitely for a national health insurance policy. Second, there was severe opposition from medical societies against compulsory health insurance. Some bleieve that "if the President had actively supported [a bill for health insurance]," it may have been passed, for"he obstacles to health insurance may have been more political than structural." Whatever the truth may have been, health insurance, once again, failed to become a national policy.

Third time's a charm? Truman Administration:
Finally, in the 1940's, national health insurance finally received full backing of the president and became a central issue of national politics. It was proposed that national health insurance be "operated as part of Social Security" and be "universal and comprehensive." In 1945, Truman asked Congress to create a national health insurance program. His plan called for expanding hospitals and increasing public health and maternal & child health services. Most importantly, the plan called for a universal health insurance system. Yet, he wanted to make sure to emphasize that iw as not socialized medicine.

Once again, there was opposition from the medical profession. The AMA went so far as to state in an editorial that the program would force doctors to become "slaves." Other health professionals were also against the plan. Additionally, there was mixed feelings about Truman's plan in Congress. As a result of such opposition, it was obvious that the health insurance plan would not be passed at this time. The furthest Truman got to passing his proposal was passing the Hospital Survey and Construction Act in 1946. While some supporters tried to continue efforts for the national health insurance plan, these efforts were axed when Republicans took control of Congress in 1946.

But, wehn Truman won the election in 1948, many Republicans believed that national health insurance would actually become a reality. Opposite sides faced off against one another. Compromises were available, such as the compromise backed by Bernard Baruch in 1947 that recommended voluntary insurance for the Americans with high incomes and compulsory insurance for the poor. Unfortunately, such compromises were never agreed upon by both sides.

Despite vagrant opposition for national insurance, there was some expansion of Social Security in other areas. First, in 1950 amendments broadened coveraged for the elderly. The amendments also "provided matching funds to the states for payments to doctors and hospitals for medical services to welfare recipients."

These amendments "confirmed the patterns of government intervention since 1935." They expanded coverage for the elderly and those who could not afford health services and strayed away from any hopes of a "single health insurance system." The presidential administration also diverged its attentions from national insurance with the onset of problems with Korea. Thus, once again, supporters of a universal health insurance filtered away.

Failure... failure... failure:
This counts three failures: first, in the early 1900's, second during the Roosevelt administrations, and, finally, in the Truman administration. Starr poses the question: "Why had reform failed?" He states that "America is frequently described as a less ideological society than Europe, more given to interest-group than ideological politics."I observed a repetitive pattern in which different parties (mostly people from labor, physician, and business groups) redundantly fight for their own interests. This commotion always focus to stray from from the central focus, creating a "single health insurance system," to those of the individual parties.

Starr also states other reasons

• The public has little control over the ultimate fate of health insurance politics because they are easily swayed by each party.
• Each party had limited resources
• Business also began to support the AMA -- employers didn't want the costs health insurance would bring and also wanted to "draw the line agaisnt socialism"
• Also, in general, ideological support for capitalism in America grew during the postwar period. This led to general opposition to any national health insurance policies.
  
• Finally, fragmentation among government agencies and individual parties that all lobbied for their own interests prevented any unified support for national health insurance.

In the end, some groups found other ways to get group coverage. Middle class individuals were able to buy private insurance and unions could bargain for collective health benefits. Also, veterans sought health care from the VA. Unfortunately, disadvantaged groups, such as the poor, were unable to secure coverage.

Personal thoughts & Connection to Present times:
Each try for a national health insurance can be characterized in certain ways:

• Liberal support for universal health care after political leaders identify key problems in the population and problems in current medical coverage
• Passionate opposition from the AMA and other medical professionals
• Split views and support from interest groups; mainly, labor, business, and physician groups
• Opposition from conservative or Republican parties
• Demise of national health care insurance reform due to conflicting views and inability to secure a unified support for reform

I believe in that the current health care reform most closely reflects what occurrence during the Truman administration. Once again, the U.S. President is providing solid support for a national health care uniform. However, one significant difference is that Obama is not backing a "single health care insurance" system; instead, he is proposing a government funded alternative to private insurance.

Just as always, physicians are vehemently against health care reform. I have personally spoken to many doctors about why they oppose this reform. First, and foremost, they believe that this insurance "alternative" will eventually become the monopoly insurance provider. This will, in their opinion, allow the government to control physicians' work by controlling reimbursements for services provided. There are several other reasons physicians are against this program. However, all reasoning centers around a single complaint: physicians do not like government intervention in their profession. Thus, as Starr states repeatedly throughout this book, physicians do not like "third party" interference that may compromise their autonomy.

From the business aspect, insurance companies have also voiced opinions against universal health care. However, I will not go into details about their opinions. Although, I believe the following website roughly estimates insurance companies' response to Obama's tries at health care reform: "Insurance Companies Laughing at Obama's Health Care Troubles"

As of yet, we do not know if this try for national health insurance will lead to success or ultimate defeat as previous tries have. But, it is very interesting to look at the parallels between current and past attempts.

Chapter 6: Escape from the Corporation

Medicine finally lost there battle to maintain "autonomy" as corporation entered medicine in the 20th century.

The Beginning: Industrial Organization
By the turn of the 20th century, there were several signs that foreshadowed the plausible creation of group medical practices. Two major changes brought about this belief: first, different industrial organizations had began contracting doctors to provide care for their employees; second, technology and specialization had increased exponentially, which could allow different medical professionals to come together and work under one roof. Many physicians, as always, were against corporate intervention in medical practice because it took away direct control physicians presently enjoyed in their profession. But, as Starr States, some physicians "viewed these organized health services, particularly the private multispecialty clinics, as hargbingers of a new order of medical care." However, even though many advances in medicine easily pointed to this step forward, such organization of medicine did not occur. Why is this? Starr provides several answers to this question by looking at different aspects of medicine between 1900-30.

First, Starr looks at "company doctors and medical companies." As stated in the previous paragraph, many industries were now contracting physicians to provide care for their patients. The first industry was railroads, who contracted physicians to treat industry-related injuries. Soon, these physicians were providing regula rmedical care to employees as well. Additionally, some industries even built their own hospital facilities for their employees.

Of course, private practitioners were against industries contracting medicines. Physicians did recognize the need of such contracting in remote areas where hospitals and health care was less available. However, overall, many physicians and "[medical societies] regarded [contracting doctors] as a form of exploitations because it enabled companies to get doctors to bid against each other and drive down the price of their labor." Thus, much opposition against company contracting came about.

"Acceptable" Corporate Influence
There were other forms of corporate interference in medical practice; but physicians were not against all such forms. First, there was the creation of health insurance. However, physicians were not against health insurance because it still allowed private doctors to obtain different patients. The second form began when private, profit-making companies began contracting groups of doctors to provide c"commercial" medicine. However, such practice was quickly barred by a series of legal decisions that said providing commercial medicine was "a corporation could not be licensed to practice and that commercialism in medicine violated 'sound public policy.'"

In the end, corporation in medicine did not flourish. First, "once [such corporations were] blocked from regulating medical decisions, they would note asily have found other ways to cut costs and achieve any price advantage over solo practitioners." Second, private doctors could work for many hours, while corporations could not require their physicians to work similar hours in fear of being oppressive. Many other reasons also contributed to the failure of corporation in medicine.

Consumer's Clubs
The next type of corporate intervention that began in the 20th century were consumer's clubs. Several "fraternal orders" sprung up in the 1900's that offered life insurance and even aid for the sick and poor. These groups were popular amongst immigrant communities, which provided a large pool of new possible members. Additionally, there were two other types of contract practice -- other private clubs organized by doctors and work/shop organizations.

These societies paid physicians low rates (about $1-2) to provide care to their members. Some physicians were not against contract medicine because it still provided care for patients and reasonable pay. And, although it may take away some business from private practice, hospitals or dispensaries were much worse "abuses" because they provided free care. However, most physicians were against contract medicine; especially the AMA, which "could see 'no exonomic excuse or justification' for lodge practice, objecting to the unlimited service for limited pay and the 'ruinous competition' it 'invariably' introduced."

Despite these critiques, contract medicine was almost essential for young doctors that used this business to "break into the field." Understanding that these societies did allow young physicians a stepping stone into the field, many physicians recognized that these groups could not be attacked at the current time. But, soon contract medicine filtered away as volunteer hospitals, etc. began providing care to a larger groups of people.

Private Group Practices
After looking at contract medicine, Starr continues on to the origin of private group practices. Group practice began with the Mayo Clinic in Rochester, Minnesota. One man and his two sons, all of whom specialized in surgery, first began their own practice here. As their notoriety increased, they began serving more and more patients -- soon they were doing about 3000 operations a year. Thus, they decided to bring in other physicians to work under them. As diagnostic tools increased, they brought in other technicians -- such as lab workers. Soon, they had established a huge clinic that provided a multitude of services. Following the example of the Mayo Clinic, many others sprung up across the country. Most, like the Mayo Clinic, were started in small towns where other large hospitals or health care services were unavailable.

The clinics had a definite class structure, both between physicians and other workers. Owning physicians were at the top, and generally around 46 years old, while employeed physicians were around 34. Unfortunately, the hierarchies created many problems. Physicians working at the "lower tier" would become upset and would have to be moved up in position. Oftentimes, these physicians were given some ownership. Other problems, such as economic conflicts, even caused some group clinics to break up.

Furthermore, as specialization and technology increased, individual doctors or hospital provided services that group practices offered at competitive prices. In the end, group practices seemed to filter away.

Why didn't corporste enterprise last?
After looking at group practice, Starr goes on to look at why there is no corporate enterprise in medical care. Case and point, physicians don't like third party interference in their practice. Furthermore, they "oppose any one else, such as an investor, making a return from physicians' labor."

The main point I took away from this section was when Starr stated that "My argument here is that the profession's success ine stablishing its sovereignty in medical care depended on the banishment of profit-making businesses from medical education and hospitals as well as from medical practice itself." At first, I did not understand this statement -- how did banishing profit-making businesses from school have anything to do with medical practice itself?

But, if you remember, medical schools were once popping up around America at alarming rates and almost spitting out under-qualified "physicians" at an even higher rate. Different schools recognized the need to control medical education. Curriculum and graduation requirements became harder and the programs, itself, became longer. Ultimately, medical schools could not exist as for-profit organizations, and reverted to non-profit organizations. Without any money-making goals, these institutions could focus on simply education physicians to the best of their capabilities.

Similarly, if physicians can exert similar control on other aspects of their profession, they can ensure that one goal, their own autonomy, is ensured.

By not allowing medicine to become a "corporate enterprise," physicians also protected their autonomy when it came to division of labor. As I've stated many times already, specialization and technology increased enormously at this time. With these changes, came a large number of new medical professionals, such as diagnosticians. Adding to existing medical workers, such as midwives, this created a lot of competition for physicians. Yet, because physicians did not allow corporate enterprise to enter their field, physicians retained their autonomy and were able to continue working as they wished. As Starr states, "As in other industries, the management of the enterprise might have sought to take away from the workers control over the division of labor, which physicians retained through the system of professional sovereignty."

Eluding Corporation
Thus, in the end, physicians were able to elude the ways of the corporation. I want to now try and make a comparison between what happened at the beginning of the 20th century, to what is now happening at the beginning of the 21st century. Like then, technology and specialization is increasing at amazing rates. New medical fields are opening up, making way to new jobs. However, the major concern how is not to dodge corporate medicine, but so-called socialized medicine. Starr states near the beginning of this chapter, "The dislike of physicians for socialized medicine is well known, but their distaste for corporate capitalism in medical practice was equally strong." I don't know if this statement is true, but I am sure that physicians are trying just as hard as their predecessors to bar third party involvement in their practice.

This is very apparent in the article Doctors Rally Against Democrat-led Health Care Reform from the Atlanta Journal Constitution. The author states, "The doctors, many who donned their white lab coats, said the legislation would create a huge government bureaucracy over health care that would come between them and their patients." Sound familiar? Yes, the same vehement argument against third-party intrusion that reappears in this chapter of Starr's book. It seems physicians have not lost their fervor in the past 100 years.

However, I believe that health care reform may be near this time around. The House has passed their own form of the health care reform bill, and the Senate is set to discuss their own rendition. Only time will tell whether or not physicians can maintain their "autonomy" this time around.

Chapter 5: The Boundaries of Public Health

I found this chapter to be the most captivating so far; probably because I'm working on a certificate in Public Health and this provides an in depth history of the field in the early 20th Century.

Beginnings of Public Health: Dispensaries
This chapter started with a section on dispensaries. I actually didn't know these existed -- they began in the late 18th century and were "medical soup kitchens," aka provided free medical care. Physicians worked their either to gain experience or used it as places to teach medical students. Some private practitioners opposed the growth of dispensaries because it "took away" paying patients. Although, it is not known if this "dispensary abuse" was as widespread as private doctors claimed, most likely it seems to me that most patients were actually poor individuals who couldn't pay for health services.

Unfortunately, some dispensaries did abuse their patients. Many patients were forced to wait hours in crowded rooms for services only to be met with grumpy physicians who offered quick, haphazard care. Besides this controversy, a majority of controversy surrounding dispensaries came from two types of doctors: affluent doctors who wanted no limits on dispensary use to use for teaching and "economically insecure" physicians who thought dispensaries took away paying patients.

In the end, dispensaries faded away due to varying reasons.

Health Departments
The next part of this chapter centers around Health Departments. Around the beginning of the 20th century, a major change occurred in public health. Public health individuals began to change focus from environmental factors to individual factors that effected health. Health departments were created because they provided venues individuals could research different factors that effected individual health and venues to treat individual health factors.

The first local and state health departments began post-Civil War when there was proliferation of epidemics of yellow fever and cholera. Besides the creation of the National Board of Health in 1879, which was later disbanded, public health has mostly been run by state or local governments. Health departments offered many innovations to medicine. First, diagnostic bacteriological laboratories were created. These labs provided physicians with tools that accurately diagnosed several diseases. Second, these labs created "serums" that could be used as cures to certain diseases. Unfortunately, many private physicians and chemists were against distribution of serums because it allowed for "unfair competition with private businesses." In the end, health departments stopped advertising and selling serums, but did distribute them to doctors for patients.

School health services also popularized at this time. Bacteriology proved that individuals could be treated for contagious diseases and could be taught to prevent spreading such diseases. Thus, different schools began hiring health investigators to identify sick children and offer treatment. Later on, nurses were utilized. Eventually, these health programs became a permanent part of schools.

"Dirt"
Starr goes on to discuss the changed view of "dirt" in Public Health. Before the 20th century, there were broad, general ways of dealing with dirt and how it effected disease. Large scale fumigations, etc. were popular. Slowly, as more information about how diseases are spread, etc. more narrow techniques or interventions were employed. Charles V. Chapin, health commissioner in Providence, RI, headed this innovative movement. Chapin supported using such techniques as washing hands, effectively "removing adenoids," etc. to help prevent disease.

The Three Phases of Public Health
This innovation was identified as the third phase in public health by C.E.A. Winslow: the first phase was from 1840-90, when there was widespread "empirical environmental sanitation;" the second phase was from 1890-1910, when bacteriology first surfaced and emphasis on isolation and disinfection was popular; finally, this "new public health" emphasized 'education in personal hygiene and the use of the physician as a real force in prevention;"

Thus, at this time, there was also an icnrease in individual health examinations. Physicians began focusing more on finding diseases early or finding ways to prevent them altogether. Insurance companies even stated that there was a reduction in mortality rates due to preventive examinations. Some campaigns were even launched to support exams, such as "Have a Health Examination on Your Birthday."

Health Centers
The final section of this chapter focuses on the "prevention of health centers." The health center movement started in the 1910's. At this time, many public health heads wanted to create health centers where all types of services would be provided: labs, x-rays, medical exams, etc. Hermann Biggs, one supporter, stated these centers could even solve the problems concerned with the lack of physicians in rural areas. Although, many physician societies opposed the creation of such centers. They believed that too much power would be given to Health Boards and not to physicians. Thus, health centers never really came into existence.

Although, as Starr states, this vehement support to withdraw government intervention is popular throughout many American professional fields. "It was a cardinal principle in America that the state should not compete with private business." More specifically to medicine, one NC county supervisor said, "You had to promise that you were going to do no curative medicine at all before you could set up a country health department." -- In other words, physicians wanted to make sure these dept centers would not take away their work.

The Golden Age
Starr concludes this chapter by stating that, despite such controversies, this time seems to be the "golden age" of public health history. There was a constant snowball of discoveries in the field at this time ranging from bacteriology, to creation of health departments. On a less optimistic note, this time also proved that public health would always be "relegated to a secondary status: less preestigious than clinical medicine, less amply financed, and blocked from assuming the higher level functions of coordination and direction that might have developed had it not been banished from medical care."

My Thoughts & Questions
After reading this ending note, I wanted to actually see what the differences in public health and medicine are. I found the following website: Public Health vs. Medicine from the Stony Brook University Medical Center website.

One interesting difference

• Public Health: Biologic sciences central, stimulated by major threats to health of populations; move between laboratory and field
• Medicine: Biologic sciences central, stimulated by need of patients;move between laboratory and bedside

The similarity here is the dependency on the laboratory. This, I'm guessing, stems from the historical precendent of how labs were started. As stated earlier, public health individuals began labs as a diagnostic tool after the conception of bacteriology. The "serums" or medicine created in labs were then distributed to physicians to give to patients. Thus, for over a century, both fields have depended on laboratories. So, it is almost common sense that this similarity would be listed.

But, the reason I use this example is the difference in which members of each field "move between." Public health is between the lab and field, while medicine is between the lab and bedside. Perhaps, one reason why public health is always "secondary" because public health individuals do not directly work with the patient. Of course, public health researchers have provided a multitude of preventive means for people, but, in the end, it is always the doctor patients go to to treat illnesses. The aid doctors provides give immediate, visible results, while public health individuals provide more long term aid. This small difference may make a world of difference.

But, this is just a thought. Many people appreciate both physicians and public health individuals for their work. Unfortunately, in life there is always competition for who or what will be "first."