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My Brother's Doctor
by Robert Tranquada '51

Health care for the indigent has been an issue in Western society for at least 1,700 years. The irony is that it has only been in the past 100 or so years that access to health care has actually made any real difference to life span or quality of life for any of us, whether rich or poor. In fact, a pretty good case can be made that it was not until the beginning of the 20th century that a visit to the doctor was more likely to be helpful than harmful.

Fourth-century hospices founded by the Benedictines actually had little to do with health care. Their functions were to provide lodging for the wayfarer, care for orphaned children and provide what was usually terminal care for the indigent sick. From the fourth century until the early 20th, there was no medical service that could be provided in the hospital that could not be provided at home. The physician's role was extremely limited. Hospital admissions were governed by rules of charity, not medical decisions.

By Elizabethan times a new class of urban poor, no longer attached to the land, had become the victims of a mercurial economy, often ruled by plagues, drought, and civil war. No longer under the care of the gentry, it became increasingly evident that these folks needed some organized level of support to relieve their suffering. Spurred on by fears of civil unrest, the Parliament of 1601 enacted the Poor Laws. These statutes required each parish (later the county) to provide an almshouse (a combination poor-house and hospital) for the "deserving poor," to be paid for by the landed rate-payers. But it was the definition of "deserving poor" that deserves our attention. The deserving poor were those whose condition was not their fault, who were therefore without sin: the elderly, infants and children, the blind and the disabled. The unemployed were seen as products of their own sloth and were not included, nor were the alcoholic, syphilitic or pregnant out of wedlock.

Since the original American colonies derived their polity from their English cousins, these traditions were carried over to the early colonies and later to the states. It is remarkable that if we analyze the eligible recipients of our original 1965 Medicare and Medicaid programs, we see provisions made for health insurance for the elderly, infants and children, the blind and the disabled.

In keeping with these traditions, the vast majority of hospitals built in the U.S. prior to 1965 were sponsored by charitable institutions, many of them religious organizations. They were totally supported by their charities, a solution that remained possible until the mid-1940s when hospital costs began to exceed $3.50 a day. (No, that's not a typographical error.) In the early 1900s, when hospitals began to provide important services not available in the home, such as X-rays, laboratories, and sterile surgery, middle-class people started using the hospital in increasing numbers, and a new formula had to be found. In a process of cost-shifting reminiscent of Robin Hood, the rich were overcharged and the profits used to support charity patients. For a time, this worked very well, and the deficits remaining could be made up by local philanthropy.

By the time Medicare and Medicaid were enacted in 1964, however, several important developments were again transforming health care. New and medically important technologies were being developed on nearly a daily basis. More and more people were seeking care for conditions that would have gone untreated only a few years before, and both doctors and hospitals were experiencing greatly increased demand. The combination of new technology and increased use led to rapidly rising costs, while the growth of commercial, employer-provided health insurance provided three-quarters of the population with the wherewithal to pay these skyrocketing bills. Then Medicare and Medicaid guaranteed that doctors and hospitals would be paid (pretty handsomely) for much of what they used to provide free. Now that hospitals and other aspects of medical care could be operated at a profit, entrepreneurs were attracted to the field and the marketplace began to play a role in the distribution of health services.

In the meantime, of course, essentially every other Western industrialized society (and some in the East, as well) had initiated some form of universal health insurance for their populations. By 1965, only the United States remained without universal health insurance coverage. Our politics and our ingrown mistrust of anything government-operated combined to ensure that we would not join the others. The most vociferous and politically effective leader in this refusal, until very recently, was the American Medical Association. The AMA came very close to approving a push for universal health insurance in 1924, but quickly reversed itself and staunchly opposed and defeated every such effort until the early '90s.

Today, as the principles of the marketplace increasingly inform the workings of health care, there is less and less room for informal charity. The provision of services to the indigent for nothing or at much reduced cost was one thing when all a doctor had to offer was his time and an office in his home, with little or no overhead. It is quite another thing in today's world, where the doctor's time is only half the cost and the provision of free services requires a cash contribution to support the paraprofessionals, equipment and other capital costs, expensive supplies and increasingly expensive pharmaceuticals.

The problem is not only that doctors and hospitals are expensive. Now stockholders must have their profit, and giving away corporate resources is frowned upon. Doctors are increasingly held to tougher work schedules and expected to increase their productivity. "Wasting" time on charity (or even teaching medical students) does not contribute to improved productivity and is not encouraged in many settings. Even not-for-profit, charitable institutions, which must compete in the marketplace against the for-profits, have reduced their charitable activities in the interests of efficiency and competitive demands.

Now, before we upset ourselves with these facts, we have to ask whether it really makes any difference whether one has ready access to health care. To make a long story short, there is overwhelming evidence that access to modern health care does make a profound difference in life expectancy and in quality of life. In addition, lack of access for the indigent substantially increases the cost of providing the care they need. Conditions that should have been cared for early are neglected until they are major problems. Care is then provided in the most expensive setting--the emergency room. Preventive services are largely unavailable, outcomes are poorer, and a substantial excess of wages is lost due to work absence.

In short--it makes a huge difference.

So, am I still my brother's doctor? Everything in my Western tradition, in my training and in my gut tells me I am--or at least should be. The medical profession in the West has long included a tradition and culture of altruism, established first by the writings of Hippocrates in the fifth century BC. Further enhanced by the great rabbi and physician Moses ben Maimon in the 12th century, and nurtured by Western religious traditions that value charity, there persists today a substantial measure of altruism in the acculturation of newly minted physicians.

Meanwhile everything transpiring in health care economics today tends to countermand that. Forty-three million Americans are uninsured--17 percent of the entire U.S. population. In Los Angeles County that number is 31 percent. Preventable human tragedies are played out every day.

There is virtually unanimous opinion that there is only one solution--some variety of universal access to health care in the U.S. Voluntary services by physicians and hospitals can no longer fill the gap. There are vast differences of opinion as to which method to use. Those of us who vote or pay for political campaigns are almost all insured and thus see the problem as simply one of welfare. Our $1.2 trillion annual health care expenditures enrich the providers (doctors, hospitals, insurance companies, pharmaceutical companies) more than adequately to finance vicious and self-serving campaigns that tend to assure that little consensus can be reached. Meanwhile the shrill devotees of one or another method of solving the problem destroy each other's strengths in the debate.

The desultory efforts currently being made to approach the problem piecemeal by enlarging Medicaid, expanding the Children's Health Insurance Program or providing purchasing cooperatives for small employers will never lead us to an adequate solution. We need to put away our Elizabethan prejudices, roll up our sleeves and create a system of universal access. Unfortunately we cannot expect to be successful until there are enough voters who feel their own security is threatened without such a plan. We are not there now. Perhaps enough middle class people will lose their jobs (and health insurance) in the current economic slowdown to convince us that our employment-based system must be replaced with one of universal access. Whether that happens tomorrow or someday in the distant future, it seems likely to be the only mechanism that will force essential change.

--Dr. Robert Tranquada '51 is the former dean of the University of Southern California School of Medicine and former chairman of the Pomona College Board of Trustees.