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
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
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.
No comments:
Post a Comment