*Remaking the American Patient*

The author is Nancy Tomes and the subtitle is How Madison Avenue and Modern Medicine Turned Patients into Consumers.  Here is one excerpt:

While unwilling to pass any kind of national insurance program, the U.S. Congress strove to advance the cause of “medical democracy” by other means.  Instead of guaranteeing a right to medical care, legislators voted to spend public funds on hospital construction and basic medical research as a means to yield more and better treatment.  To make that treatment affordable, the federal government looked to the private sector for help, using tax policy to encourage the growth of employee insurance plans.  In this fashion, postwar political and business leaders hoped to create a free enterprise alternative to “socialized” medicine.

The first step toward expansion came in 1946 when Congress passed the Hill-Burton Act, which funneled federal funds into hospital construction and expansion.  Over the next two decades, Hill-Burton funds would be used on almost 5,000 projects, many of them in rural areas that previously had had no hospitals.  The program proved very popular, giving local communities a new institution to be proud of while creating more “doctors’ workshops” for medical education and private practice.  At the same time, Congress vastly increased funding for medical research, from about $4 million in 1947 to $100 million by 1957.  Postwar political leaders found appealing the idea of tackling cancer, mental illness, and other dread diseases through “a medical research program equal to the Manhattan Project,” as the National Health Education Research Committee urged in 1958.  Taxpayer dollars helped to build up the National Institutes of Health (NIH) in Bethesda, Maryland, as the hub of what a later generation would christen the “medical-industrial complex”: a network of researchers located in American universities and scientific institutes whose careers depended on the generation of medical innovations.

I found this book extremely useful for understanding the evolution of American health care policy and institutions before 1965.


If only people who need health care didn't act like consumers. That is the mantra of socialized medicine everywhere.

After a series of disastrous policy decisions (mostly warmed over Marxist stupidity) and the Canadian health care system was close to collapse, the ideologues would remind us that it was our duty to wait for years for the medical procedure we needed because it was the best system in the world. How dare we worms demand timely service in exchange for the government letting us keep half our wages!

Since you were almost certainly waiting for an elective procedure, I don't think we need to distribute the cry towel just yet.

And how else is the government going to ration this type of non essential medical care? I suspect if it DIDN'T, you'd have your knickers in twist about THAT.

Final Question: what are you doing living in a Single Payer hellhole like Ca? Get out while there's still time!

Yeach, come to the US and a Red State. Cash up front, or you wait until you have the cash. Many places in the US the waiting times are infinite.

Heh. I love it when wanny be totalitarians justify the mismanagement of their responsibilities.

If you knew anything at all you would know that the problem wasn't being able to pay. It was that stupid decisions half a decade previously had limited training and recruitment of nurses and doctors in the fantasy goal of limiting demand. There were operating theatres that couldn't be operated because there weren't enough nurses. The waiting list for a pregnant woman to see a GP was 13 months.

Elective isn't used any more in Canada it has such a nasty connotation. Something like compliant used by the cop justifying shooting someone. It is elective if you aren't going to die immediately. Sometimes cancer takes 6 months or more to kill you so getting to see a specialist in a timely fashion was considered elective. No harm waiting 4 months. And if you blow your knee, why can't you wait for two or three years for surgery, you ingrate.

If the 'if you blow your knee' is torn meniscus cartilage, there's no better outcomes from having the arthroscopic surgery *


* more generally, we certainly hope you're not of the 'entitled unwashed' driving excessive health care costs through 'overuse'

My wife's grandfather, a proud Canadian, was told at age 82 that he would die within two years without a quad bypass and that because of his age Canada didn't think it was cost effective so good luck. He could have driven a couple hundred miles South and had the bypass within a week in a country with the worlds best health care but he would have had to pay for it. He choose not to and passed away almost exactly two years later. Socialized health care requires rationing and excluding. Simple as that.

Paying for something out of your pocket is also rationing and excluding..

Simple as that.

Life expectancy at age 82 for males in the U.S. is 7 years so any discussion of treatment for men past age 80 isn't about "saving" their lives but is rather about the probability of buying a few months or years at most. The U.S. has a form of socialized medicine for senior citizens as well so it is unavoidable to ask how much tax money we should be willing to spend on cancer or heart disease treatment for the elderly. Cash paying patients would, of course, face the same questions and stark trade-offs themselves.

Life expectancy at age 82 for males in the U.S. is 7 years so any discussion of treatment for men past age 80 isn’t about “saving” their lives but is rather about the probability of buying a few months or years at most.

Medicine is never about "saving" lives...just prolonging and hopefully enhancing.

My father's best friend -- also a proud Canadian -- had a cancerous kidney removed at ~83. Later the surgeon told him "oh, I misread your age. If I'd known you were that old, I wouldn't have operated. We tend to do nothing about patients over the age of x [it's not clear what age he specified]".

The plural of anecdote is not DATA.

Yet if it were an emergency situation you'd get treatment right away (hours, days, weeks, depending on what's "right away" due to whatever variety of tests, etc., might be needed).

It is not difficult to find average wait times for a variety of procedures in Canadian provinces. Maybe you can find some special outlier (you mention something in the range of years), but that's not at all the norm.

Perhaps you're thinking of a "horror story" described recently by someone who basically didn't know how to navigate the system and their doctor didn't help them, and they spent years in excruciating pain unable to get referrals, and then referrals taking forever to come through.

The issue with those ridiculous wait times (yes, I know, some are too long on average) is generally because people don't know how to navigate the system. So, in medicine, it is increasingly understood that part of the role of the doctor is precisely that: help the patient navigate the system. (But they also serve as gatekeepers not to waste scarce resources, and being human, surely they will make some mistakes.)

Anyways, if someone were agitating for private sector options, there is always the option to enjoy American pricing.

"...business leaders hoped to create a free enterprise alternative to “socialized” medicine."

Emphasis on business leaders, meaning construction and factory owners.

Well before WWII, and during it, employers paying hospitals and doctors to provide prepaid health care was the free market solution, beyond the Federal government providing health care services after the Civil War through a huge network from of facilities that were merged into the VA in 1930.

Harry Truman proposed building a rational health care system.

Congress, under pressure from the free market agents crafted the ugly compromises that try to bring order to the free market.

And the selling of medicine did not need Madison Avenue. What has Madison Avenue done to match the 19th century Hamlin's Wizard Oil Company, Kickapoo Indian Medicine Company, or Saturday Evening Post and Woman's Home Companion?

The US subsidizes the rest of the world in R&D in medical technology. That's why it's so cheap outside the USA to use cutting edge tech invented in the USA--they don't pay for it, sometimes literally as in the case of India which refuses to pay any royalties for patented medicine on 'ethical' grounds. A failure of patent policy (WIPO for example, where patent royalties should be tiered by law according to a country's ability to pay). I don't expect however this book to get into this issue, it's probably written by a historian. It's doubtful whether even patents are mentioned except in passing, and probably something negative like 'the huge costs associated with a patent monopoly' or such nonsense as is befitting a historian or college textbook economist.

"they don’t pay for it, sometimes literally as in the case of India which refuses to pay any royalties for patented medicine on ‘ethical’ grounds. " False. India just has a better patent system that lacks the idiocies of the US system that the pharmaceutical manufacturers enjoy exploiting. http://blogs.wsj.com/indiarealtime/2015/03/19/inside-india-indias-fight-against-big-pharma-patents-is-a-just-war/

The US is subsidizing the rest of the world, but that's not the only reason the US is expensive.

There are lots of reasons the US has the most expensive health care in the world. But most people stop as soon as they see the answer they want to hear and then shut their ears.

Thanks. But it's not like the subsidy was out of the goodness of their hearts. Much of it relates to corporate electoral influence to protect income flows in the industry.

I can see why people might object to socialised medicine, but I'm at a loss to see why they defend the current American system as "free market" when it so conspicuously isn't. Would "monopolistic racketeering enabled by government" be nearer the mark?

I am puzzled at the objections to "socialised medicine" as if it were all one thing. You are allowed to copy the French or Singaporean systems, you know: the NHS is not a compulsory model.

Obviously, yes. As is often the case, deadlock come from calling what we have "free market" and the alternative "socialism."

Black and white thinking strikes again.

why they defend the current American system as “free market” when it so conspicuously isn’t.

Lots of people, on both sides of the aisle, believe this:

"The US has system A. That's a free market system. Every other country has system B. It's a government-run system."

This is obviously wrong. There are wonks on both sides who will tell you how wrong this is. But it's believed, and believed strongly.

" a free enterprise alternative to “socialized” medicine."

Free enterprise? The description is far more aligned with Sumner Slichter's "government-guided enterprise" which was the order of the day coming out of the War.

"To begin with, it is severely circumscribed by the government, as Professor Sumner H. Slichter has said, one of the basic changes which have taken place in America during the last fifty years [1900-1950] is "the transformation of the economy from one of free enterprise to one of government guided enterprise....The new economy," says Dr. Slichter, "operates on the principle that fundamental decisions on who has what incomes, what is produced, and at what prices it s sold are determined by public policies." The government interferes with the course of prices by putting a floor under some, a ceiling over others; it regulates in numerous ways how goods may be advertised and sold, what businesses a corporation may be allowed to buy into, and how employees may be paid; in some states with Fair Employment laws it even has a say about who may be hired. "
----'The Big Change: America Transforms Itself 1900-1950' (1952), Frederick Allen Lewis

We see this also in the expansion of the ancient concept of 'Maintenance and Cure' in Admiralty law, the responsibility of the vessel for injuries to seamen for the duration of the voyage, into shore-side workers compensation. But the idea that the employer provides sustenance and medical services to employees evolves from the feudal relationship between lord and vassal. This concept, perhaps unconsciously, was transferred to the corporation and employee in the late-19th and early 20th century with the change being to creating a legal claim rather than noblesse oblige.

Unfortunately, this trend to a neo-feudalism usurped the liberties previously won to the free Anglo-Saxon man and rendered him to "ward of the state" condition in which women were legally considered prior to their suffrage.

p 209
"For instance, it is a primary principle that an English free man of full age, under no disability, may control his person and his personal activities. He can work six, or four, or eight, or ten, or twelve, or twenty-four, or no hours a day if he choose, and any attempt to control him is impossible under the simplest principle of Anglo-Saxon liberty.

"Yet there is possibly a majority of the members of the labor unions who would wish to control him in this particular today; and will take for an example that under the police power the state has been permitted to control him in matters affecting the public health or safety, as, for instance, in the running of railway trains, or, in Utah, in labor in the mines. But freedom of contract in this connection results generally from personal liberty itself; although it results also from the right to property; that is to say, a man's wages (or his trade, for matter of that) is his property, and the right of property is of no practical use if you cannot have the right to make contracts concerning it.

"The only matter more important doubtless in the laborer's eye than the length of time he shall work is the amount of wages he shall receive. Now we may say at the start that in the English-speaking world there has been practically no attempt to regulate the amount of wages. We found such legislation in medieval England, and we also found that it was abandoned with general consent. But of late years in these socialistic days (using again socialistic in its proper sense of that which controls personal liberty for the interest of the community or state) it is surprisingly showing its head once more.

p 213
You can have regulation of the hours of labor of a woman of full age in general employments, by court decision, in three States (Massachusetts, Oregon, and Illinois), … but the Oregon case, decided both by the State Supreme Court and by the Federal Court in so far as the Fourteenth Amendment was concerned, after most careful and thorough discussion and reasoning, reasserted the principle that a woman is the ward of the state, and therefore does not have the full liberty of contract allowed to a man."
Muller v. Oregon. 208 U. S. 412.
--Popular Law-making: A Study of the Origin, History, and Present Tendencies of Law-making by Statute, Frederic Jesup Stimson (1910)

I tried reading this book myself, but couldn't get into it. The author's views are rather interesting though!

If you put it that way, it's easy to see how it might have seemed like a good idea at the time.

But the evidence is in. More expensive than anywhere in the world by any means of calculation, and worse results than almost any country that can be remotely considered as wealthy.

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