Über die Autorin bzw. den Autor

Auszug. © Genehmigter Nachdruck. Alle Rechte vorbehalten.

HEALTH CARE FOR SOME

THE UNIVERSITY OF CHICAGO PRESS

Contents

INTRODUCTION..........................................................................ixRATIONING AND RIGHTS History and Definitions.........................................xvPROLOGUE Rights and Rationing before 1930............................................xxivONE A Crisis of Access...............................................................3TWO Social Security without Health Security..........................................21THREE Health Care at War.............................................................39FOUR Rights to Refuse: The Triumph of the Hospital...................................63FIVE Rationing by Coverage: The Rise of Private Health Insurance.....................90SIX Entitlements but Not Rights: Medicare and Medicaid...............................117SEVEN The Rise of Health Care Activism...............................................143EIGHT Emergency Rooms and Epidemics..................................................169NINE At the Breaking Point...........................................................188EPILOGUE Rights, Rationing, and Reform...............................................212ACKNOWLEDGMENTS.......................................................................223NOTES.................................................................................225GLOSSARY..............................................................................265BIBLIOGRAPHY..........................................................................271INDEX.................................................................................293

Chapter One

On a wintry Chicago morning in 1936, ten-year-old Vera Lahr began complaining of stomach pains. Suddenly, she doubled over and started vomiting "green stuff." Her panicked mother immediately called the charity clinic where she had been taking the children since their father lost his job. Now that the family was "on relief," they could no longer afford their former family doctor, but the clinic told Mrs. Lahr to call him anyway since there was nothing they could do for the sick girl. Mrs. Lahr phoned the doctor several times and even sent one of her other children down to his office. Hours passed, but "still he did not come." Later that afternoon, the doctor sent word that he would be over "after office hours." When he finally arrived, he immediately ordered the girl hospitalized. Shortly after surgery disclosed her burst appendix, Vera Lahr died.

The Lahrs claimed that Vera lost her life because she was a clinic patient and her family was on relief. Her grieving father told an interviewer that he "blamed the doctor's indifference, and the lack of immediate medical care as the cause of his daughter's death." Although they had known the doctor for years and even considered him a friend of the family, the Lahrs felt that he was annoyed with them "because they had not been doctoring with him in recent years ... they had been going to clinics where services were free." The family believed that by accepting charity medical care they had lost their standing with their former physician—a loss that, in her parents' eyes at least, cost Vera her life.

Despite its unusual drama, Vera Lahr's story encapsulates many of the changes that ordinary Americans experienced when seeking medical care during the Great Depression. Like Vera's father, millions of breadwinners found themselves suddenly out of work and turning to relief in the form of government cash or work assistance. Relief checks were inadequate to cover a family's most basic expenses, much less medical costs, and local relief authorities' responsibilities did not include financing health care. Large numbers of families attended "free" or charity clinics or used public hospitals for the first time during the Depression. Public and charity facilities that had been designated for the poorest of the poor now overflowed with the newly impoverished—people who had previously been able to afford private doctors but could no longer do so. As the formerly employed and their families found themselves suddenly flung into medical indigence, the public-private health system struggled to accommodate the new demand.

With no coordinated system to care for them, the newly indigent had to navigate a complicated patchwork of rationed services: government and voluntary hospitals, charitable physicians, private and public clinics and dispensaries. Each service had different requirements for access or eligibility; a patient rejected for one type of care might be eligible for another, but the standards proved variable and sometimes mysterious. Facilities could be difficult to get to and far from each other, making transportation a crucial part of access—in Vera Lahr's case, a matter of life or death. If the Lahrs had been able to call an ambulance Vera might have made it to a hospital sooner, but Chicago in the 1930s had no public ambulances, and the city's 22 private ambulances were too expensive for people on relief. No US city had a coordinated plan for emergency health services during the Depression, and the clinics on which the poor depended were not equipped to deal with emergency cases.

Access to private physicians depended on ability to pay or the doctor's willingness to provide care at reduced rates or free of charge. As the Lahr case illustrated, the Depression brought physicians' ambivalence about charity care to a head. Some physicians supported the expansion of charity and government clinics and hospitals to relieve the medical profession of the growing burden of free care, but others deeply resented free or low-cost facilities for luring away patients who had previously been willing or able to pay doctors' fees.

The health care system of the 1930s not only failed to guarantee access; it also offered no rights of recourse for people who were denied medical care. After the Lahrs lost Vera, they complained only to a social work student who interviewed them for her thesis on health care in their West Side neighborhood. There was no official way for patients to make themselves heard about neglect or poor treatment from doctors or hospitals. Even if the family had wanted to take their doctor to court, malpractice law offered no course of action for patients who had been denied medical care, since malpractice could occur only after treatment by the physician had begun.

The sudden increase in the need for affordable health care during the Great Depression directly challenged the ideology and institutions of voluntarism. Physician charity, private philanthropy, and voluntary hospitals and clinics, despite their best efforts, proved incapable of meeting the demand. As the economic crisis deepened, many leaders of voluntary institutions argued that the new conditions required an increase in government's responsibility to subsidize care of the indigent sick.

The role of government itself was undergoing massive change during the Great Depression. Workers, the unemployed, and the elderly joined together in vocal organizations demanding an increased federal role in the economy and in the protection of ordinary people's security. The programs of Franklin D. Roosevelt's New Deal embodied many of these new ideas about government responsibility. This was a time of talk about economic rights and security. It is no coincidence that the first...