Formative Years

The patterns of medical practice and its financing in the United States developed between 1894 and 1954. Scientific advances, interest group clashes over power, and underlying social attitudes about race and class shaped its development. Just as early childhood experiences shape a person, so these early years shaped most of what continues to be distinctive about the American health care system.

During this period other industrialized nations, faced with the same rapid improvements in medicine, explored ways to best distribute its benefits. The historical narrative of these other nations said, in essence, "for all our differences we have a common identity, and, just as in any functional family, we look after each other." The universal health insurance systems created in every other wealthy industrialized country became a way of expressing that common bond, the fundamental moral conclusion that no one should be denied needed medical care (see Reid 2010: 237-39).

That never happened in the United States (Hoffman 2012). Indeed, in terms of a national health care system, the United States produced the lone, stunted outlier. Its health care costs tower over other industrialized nations — more than twice the median per capita cost and twice the percentage of its gross domestic product are allocated to health care. Yet it has fewer physicians and hospital beds per capita, and its citizens receive fewer services (Squires 2011). The United States does poorly in comparison to other nations on most measures of health. For example, it ranks twenty-seventh out of thirty-four developed nations in life expectancy at birth (OECD 2014). About 16 percent of our citizens remain uninsured, and at least a similar percentage are underinsured, making any major medical expenses unaffordable (Majerol, Newkirk, and Garfield 2014, 4). As a result, people still go untreated and die, despite all the well-meaning patchwork arrangements worked out, because they can't afford the care they need. Other industrialized nations don't allow this to happen. What made the United States different?

The explanation offered by many and supported by some persuasive statistical evidence is that the US health system was, in essence, the "child" of the national equivalent of an abusive, dysfunctional family. Its formative period of development, between 1896 and 1954, corresponded to the Jim Crow era — between the assertion of the legality of segregation (Plessy v. Ferguson, 163 US 537 [1896]) and the assertion that separate could never be equal (Brown v. Board of Education of Topeka, 347 US 483 [1954]). That contradiction was first brought to public attention in Gunnar Myrdal's influential book The American Dilemma: The Negro Problem and American Democracy (Myrdal 1944). Indeed, the book was cited in the Brown decision. Myrdal was optimistic, arguing that the American creed of democracy and fairness would, in the long run, win out over segregation and racism. Yet so much of the structure of all aspects of life in this nation was shaped in those formative years. In no area was this truer than in the structure of America's health system. Those formative years produced all the peculiar characteristics of the nation's health system and the ideological justification for these peculiarities. Just as with the child raised in an abusive dysfunctional family, it's hard to undo the destructive effects of such a formative experience. This book tells of the struggle to do just that. That struggle was a national one and not one limited to the boundaries of the Jim Crow South. The forms it would take in the North would be different but the outcomes much the same. I have chosen to focus on Chicago to illustrate this throughout the remainder of the book, but most other northern cities could have served this purpose just as well.

Race, indeed, has always been a concealed part of the logic of "American exceptionalism." Simply creating anti-discriminatory laws or regulations or professing good intentions doesn't change this. Race, and the logic of white supremacy, is hidden in the compromise patchwork solutions, the expansion of private insurance, the creation of producer cooperative solutions in the form of voluntary Blue Cross plans, the creation of the dominant voluntary hospital sector, the ideology of individualism, the opposition to public solutions, and the promotion of freedom of choice and free market solutions that have dominated, and continue to dominate, health care in the United States. All these policy choices have a disparate impact on blacks and other disadvantaged minority groups. The notion of "social solidarity" invoked in other countries, never came up as an argument for universal protections in the United States. Only during the civil rights convulsions of the 1960s did the notion of "being all in it together" have any salience. Medicare, in its essence, was the gift of the civil rights struggle. Yet the patterns of thinking developed in those earlier formative years persist, most recently in the resistance to the implementation of Obama's Affordable Care Act.

The methods of imposing racial segregation during the first half of the twentieth century differed in the North and South, but the underlying assumptions were the same. In the South, Jim Crow laws drew visible color lines reflecting the rigid caste system created during slavery. In the North, laws and customs created more invisible but just as effective color lines around black ghettos, insulating whites from the great wave of black migration to northern urban centers from the South during this period. In both, violence defended the color lines when other means failed. The degree of segregation in northern cities, such as Chicago, was equal to that of anywhere in the South. Thus, from the failure to address the aftermath of slavery, a regionally intertwined caste system emerged in the United States. That caste system was, in turn, reflected in the early organization and financing of its health system. Those who grew up or began their medical careers before the 1960s have vivid memories of how it all worked. There was nothing functional about it. Many spent the rest of their lives fighting to change it.

The Jim Crow South

The images of the Jim Crow South still shock. The abject poverty of rural blacks in the Deep South matched any in the underdeveloped world. Many still inhabited the antebellum slave shacks and were increasingly unemployed as a result of the growing mechanization of cotton farming. They lacked access to clean water, basic sanitation, and adequate nutrition, to say nothing of medical care. As a result, when in 1966 a federally supported Office of Economic Opportunity health center was finally set up in the Mississippi delta it proceeded to violate all the conventional boundaries of medical practice.

In the absence of any other resources, whenever we saw a child suffering this combination of infection and malnutrition, we wrote prescriptions for food. ... Not just for the sick child, but for all the...