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As economist S. City-wide hospital surveys applied similar measures to their particular areas. These measures—in addition to more direct efforts—sought to control capital investment in hospitals and reconfigure hospital market structures. The combined strategies reinforced the growth of large, centrally managed, revenue-generating specialty departments in acute care hospitals serving defined market areas.
The Philadelphia County Medical Society's Committee on Hospital Efficiency surveyed the financial status and technical capacity of its area's hospitals in Physicians were clearly active on this and subsequent hospital survey committees, but it was not medical or scientific expertise that drove them; it was business expertise.
Whereas foundations played a significant role in national health policy, it was local business-organized community chests that sponsored the Cleveland Hospital Council's survey and many other city-wide hospital surveys. Cleveland's survey ranged in focus from public health administration to management of hospital revenues and expenditures.
Cleveland's follow-up evaluation concluded that its survey resulted in several successful outcomes, including directing bond-issue and community chest dollars to a new city hospital. In New York City, local donors were also national foundations. Yet, the survey justified the city's large numbers of hospital beds relative to the APHA standards in terms of its prominence as a regional medical teaching center.
Use of capital accounting was also a major focus of an ambitious national study employing survey among other techniques. With Emerson, Davis, and Sydenstricker in its leadership and funded by 8 major foundations, the to Committee on the Costs of Medical Care CCMC conducted and commissioned a range of studies designed to formulate health care policies. The committee's more conventional historical reputation for supporting universal access, 44 although not inaccurate, rejects or at least neglects CCMC's economic priorities.
Significantly, a CCMC report also included the use of epidemiology-based health planning methodology. A number of the committee's surveys measured illness prevalence, and its Fundamentals of Good Medical Care report developed measures of population need for services based on morbidity rates and treatment requirements the latter were contingent on physician opinions. Relief agencies expanded their participation in hospital surveys, but the subsequent reports were not substantively different in perspective and remained resolutely voluntary in the face of New Deal governmental planning.
Boston also reported that its high-debt hospitals were having trouble paying interest costs and recommended that they adopt the managerial measures employed by for-profit organizations. The survey administrators explained that their purpose was to manage capital and operational costs of area hospitals 52 and develop an empirical base for the economic evolution of organized facilities. As commissioner of the city's Department of Hospitals, S.
Emerson tried another way to steer an economic approach. Any discussion this list may have engendered does not appear in the survey files, but the questions alone reveal the survey's concerns. In so doing, the reports challenged the dilution of capital across a large number of institutions in favor of fewer, more capital-intensive and higher-cost institutions. A very brief look at surveys conducted in other cities reveals economic tactics similar to those discussed thus far.
As chairman of San Francisco's community chest hospital committee, Stanford University president Ray Lyman Wilbur oversaw its survey that advised restricting general hospital growth while recommending that Stanford but not its tax-supported rival, the University of California receive special funding consideration as an academic institution.
Bachmeyer, dean of the city's medical school, charged that empty hospital beds were wasting community chest dollars and recommended a moratorium on adding acute care beds. The surveys from the Progressive Era through the New Deal demonstrate the extent to which a wide range of cities chose this reform method to shape hospital development. The surveys show that, contrary to a range of historical interpretations, 75 economic strategies have played a leading role in health reform activities for more than a century.
None of the hospital surveys employed all of the tactics discussed here, and the surveys did not always use economic terminology to describe the strategies used; in essence, however, they promoted methods that controlled capital investments and markets. To manage investments, surveys appraised hospitals in terms of financial assets and concentrated capital in an effort to maximize efficiency and productivity via full-capacity use of facilities and technologies.
To manage markets, surveys sought to consolidate hospitals, control competition, confer competitive advantage, and build oligopolistic market structures. What were these tactics, borrowed from profit-making industry, all about in nonprofit institutions? They were not necessarily about individual financial incentive, as market theory propounds. They were about concentrating wealth and power in dominant medical and business institutions.
The New York Times had alluded to the rule that capital donations had to be invested in buildings and technology that could continue to expand and increase the value of the capital. Maximizing the productivity of costly specialties and their technologies was another rule. CCMC's Rufus Rorem advised the Taylor Society for the Advancement of Management that efficient use of fixed capital required maximum use of hospital plant and technology.
Yet it was not all business; commerce and idealism have long coexisted in health policy history. Haven Emerson endorsed business practices as necessary for institutional efficiency, and he assumed that this efficiency was consistent with the philosophy of service that he often expressed in his speeches.
It is difficult to measure the extent to which surveys actually shaped hospital development, and of course it is impossible to do so from a study of the surveys themselves. The surveys formed a part of the many social, economic, and medical factors that shaped hospital growth. It is reasonable to expect that, like the Cleveland Hospital Council, agencies that commissioned surveys to help them decide which hospital building projects to fund or endorse did use them for that purpose.
A CCMC report further concluded that community chests and their surveys exerted considerable power over local philanthropic and corporate donations to hospitals. The surveys also had a significant impact on future health reforms, contributing directly to the establishment of hospital councils in many cities. The extent to which these councils implemented survey recommendations remains a question for further research. The federal government tried again to organize hospitals in the s, when it attempted to control the growth it was paying for in the Medicare and Medicaid programs.
In reimbursing operational and some capital expenses of treating elderly and low-income people, Medicare and Medicaid shifted considerable financial risk to government without changing hospital ownership or management structures. In addition to the city-based surveys and the regional surveys required by the Hill—Burton program, health planning signified a third major 20th-century policy attempt to shape hospitals and hospital systems.
Certificate of Need CoN , which surveys proposed initially as a voluntary measure, was established in New York State in as a publicly sponsored review of hospital capital expenditures. The 2 national health planning programs based their actions on both economic planning that sought to rationalize production systems and social planning that sought a more equitable distribution of their products.
At best, planning could only pay lip service to supporting innovative primary care approaches such as community health centers. Economist Kenneth Arrow's article strongly influenced thought on planning and the Certificate of Need. But at the same time, it legitimized measuring health care against the economic norms of the competitive model. The more than area agencies and regional advisory centers in the federally funded health planning network strove to adjust hospital markets.
Local agencies surveyed service supply and applied formulas many of which were derived from industrial planning designed to adjust supply to effective demand as defined by actual use. They did summarize epidemiological data about their areas, but the required methods did not and could not incorporate this information into projections of resource needs.
On the basis of the interests of medical specialty associations as well as economic assumptions, federal health planning guidelines established minimum volume and use criteria that favored consolidation of hospitals and specialty services. A good case can be made, both socially and economically, that there has been and is a surplus of high-cost specialty services.
A benefit of consolidation is higher efficiency in the use of the particular technologies and procedures that demonstrate economies of scale many do not. The other side of the coin, however, is that consolidation reconstructs health care as an industry comprising high-cost institutions irrespective of population need.
The National Bureau of Health Facilities and its regional advisory centers further contracted with accounting and management consulting firms to train health planners in financial formulas and rules for preserving capital. The health planning sector partially accommodated to the growing supply-side view, and its health systems agencies participated in building the business—health care coalitions that would come to replace them.
Business, for its part, appreciated the extent to which capital investment rules shaped health system infrastructure. Further promulgating financial rules in the name of the market , they forced the same kinds of mergers and reorganizations resisted under government planning and regulation. Many of their tactics entail the strategic use of capital. There is no doubt that there has been a huge attitudinal and rhetorical shift in health reform over the past few decades from social to economic and from health to cost control.
Long-standing tensions remain between economic and social goals and between market and regulatory means in health reform. Although concerned with the health of the public, reformers involved in hospital surveys and health planning nourished the development of capital-intensive specialty facilities and starved primary and chronic care. Reducing the high costs of medical care requires altering the structure of high-cost medical care.
Meeting public health needs requires not just equitable access to existing services, as crucial as that reform is, but designing alternative forms of health care delivery. A bonus is that many potential alternatives may be less costly. Social medicine still poses a pair of important but extremely difficult challenges to social and health reform. The first takes on the social and economic roots of illness. Past failures to change unhealthy social and economic conditions and build services that match needs may indicate an inability or unwillingness of progressive reformers to question the work and identity of the business, medical, and academic institutions in which they are embedded.
Social medicine's disparity between goals and means may also mean that the task is literally inconceivable in prevailing economic climates. The second challenge—still daunting but somewhat less threatening and potentially a major step forward—is to develop admittedly bureaucratic planning methods in which available scientific evidence is used to match the nature and quantity of health care services to population illness.
Because most illnesses do not require or benefit from complex care, such an epidemiological approach also would seriously challenge existing institutions and organizational models. Just as the depression of the s reinforced social medicine ideas, the inflated growth of recent decades and the capital crisis it engendered may offer a rare opportunity to question economic and medical orthodoxies usually taken for granted.
It is simplistic to declare that planning is the problem and that everything will automatically be solved by a shift to the market. It is similarly simplistic to advise that privatization is the whole problem and that everything will automatically be solved by making private services public.
The health policy sector needs to learn from past reforms that built high-cost medicine. It needs to design a social model of health care delivery and a way to substitute it for the current business model. Different versions of this article were presented at meetings of the Policy History Conference St. I thank Guy Alchon for his trenchant comments and Martha Livingston for her invitation; also, I thank the editors and anonymous reviewers. National Center for Biotechnology Information , U.
Am J Public Health. Barbara Bridgman Perkins , PhD. Author information Article notes Copyright and License information Disclaimer. Barbara Bridgman Perkins works as an independent scholar. Corresponding author.
Accepted August 11, Abstract Inspired by social medicine, some progressive US health reforms have paradoxically reinforced a business model of high-cost medical delivery that does not match social needs. Open in a separate window. Marketing to the growing hospital industry. Hospital Management September , Philadelphia, Pennsylvania The Philadelphia County Medical Society's Committee on Hospital Efficiency surveyed the financial status and technical capacity of its area's hospitals in Cleveland, Ohio Whereas foundations played a significant role in national health policy, it was local business-organized community chests that sponsored the Cleveland Hospital Council's survey and many other city-wide hospital surveys.
Louis, Missouri St. Committee on the Costs of Medical Care With Emerson, Davis, and Sydenstricker in its leadership and funded by 8 major foundations, the to Committee on the Costs of Medical Care CCMC conducted and commissioned a range of studies designed to formulate health care policies. Other Cities A very brief look at surveys conducted in other cities reveals economic tactics similar to those discussed thus far. Energy efficiency and renewable energy are smart investments that result in savings over time while supporting green jobs.
This will allow us to grow our Green Power solar apprenticeship program to create career pathways in solar power while making progress toward the critical goal of reducing our carbon emissions. Continuing to invest in flood mitigation projects based on recommendations from watershed studies that have been underway since Accelerating the investment in LED light-emitting diode streetlights with the goal of converting all remaining streetlights to LED by The renovated station will make long overdue improvements to ensure the workplace conditions are inclusive for all Fire Department staff.
The additional capacity at the station will also ensure we are able to provide fire services to Town of Madison residents following the attachment in fall Renovating the first floor of the City County Building. As the home to the Parks Division, City Clerk, Treasury, and Assessor, this is first stopping point for our residents when coming to interact with their City government.
Now, it is more important than ever to ensure these spaces are safe for City staff while continuing to be welcoming to our residents. This move will ensure our staff are equipped with current tools to do everything from analyzing and presenting data to communicating with the public and their teams in an efficient way.
This approach will allow us to stay current as updated IT tools are available.
Roughly 20 million additional Americans obtained the peace of mind that comes with health insurance. But, every day over the past ten years, the Affordable Care Act has been under relentless attack. Immediately after its passage, Congressional Republicans began trying again and again to repeal it.
Following the lead of President Trump , Republicans in Congress have only doubled down on this approach since January And, since repeal through Congress has not been working, President Trump has been unilaterally doing everything he can to sabotage the Affordable Care Act. Now, the Trump Administration is trying to get the entire law — including protections for people with pre-existing conditions — struck down in court.
As president, Biden will protect the Affordable Care Act from these continued attacks. He opposes every effort to get rid of this historic law — including efforts by Republicans, and efforts by Democrats. Instead of starting from scratch and getting rid of private insurance, he has a plan to build on the Affordable Care Act by giving Americans more choice , reducing health care costs , and making our health care system less complex to navigate.
For Biden, this is personal. He believes that every American has a right to the peace of mind that comes with knowing they have access to affordable, quality health care. Since , the number of uninsured Americans has increased by roughly 1. As president, Biden will stop this reversal of the progress made by Obamacare. Today, even for people with health insurance, our health care system is too expensive and too hard to navigate.
Biden will not only provide coverage for uninsured Americans, it will also make health care more affordable and less complex for all. The Biden Plan has several additional proposals aimed directly at cutting the cost of health care and making the health care system less complex to navigate. As President, Biden will:. Too many Americans cannot afford their prescription drugs, and prescription drug corporations are profiteering off of the pocketbooks of sick individuals.
Biden will put a stop to runaway drug prices and the profiteering of the drug industry by:. Presidential candidate Sen. Elizabeth Warren, D-Mass. Her crusade against the wealthy of America has rankled donors and politicians in the upper echelons of both the Democratic and Republican parties but has resonated with potential voters ahead of the Democratic primaries.
On the campaign trail, Warren's Ultra-Millionaire Tax has become her signature and most popular policy. Warren's Excessive Lobbying Tax aims to deter corporations and trade organizations from influencing government through high spending. The money raised from the taxes would be committed to Warren's "Lobbying Defense Trust Fund," dedicated to strengthening government against the influence of lobbyists.
Warren's zeal for taking on big corporations in the wake of the financial crisis sent her to the forefront of financial reform, and her tax on corporate profits is yet another way she plans to tax wealth. A significant part of Warren's policy agenda includes the expansion of Social Security, which she hopes will be the biggest increase to the retirement program in 50 years. It would be financed by a The Tax Cuts and Jobs Act was one of the biggest and most controversial bills passed by the Trump administration.
Warren joined a chorus of opponents to the bill who considered it a giveaway to corporations. If she were to win the presidency, a core part of her agenda would be rolling back the legislation and restoring the previous corporate tax rate. The money raised from the tax would fund gun violence research and prevention, while reinforcing existing gun laws. Warren also has her sights set on the private equity industry. Her plan is not specific on costs or rates yet, but her Wall Street reform plan promises to change tax rules so that firms "that make bad investments would be held accountable instead of walking away from the wreckage with millions in fees and payouts.
As part of her climate change agenda, Warren aims to have the military achieve carbon net-zero emissions by While Medicare for All was first proposed by presidential candidate Sen. Bernie Sanders, I-Vt.