Does Better Transportation Translate to Better Health?

By Leslie Charles Coover

In the early and mid-nineteenth century, the majority of the U.S. population was dispersed in rural societies and they lacked modern transportation. Most people were cut off from access to healthcare because of the high cost of travel. For a farmer who had to travel ten miles to take a family member to see a doctor, the travel time could mean a whole day’s lost work (Star). In most areas, according to one Illinois practitioner, “The doctor did not often go more than ten miles from his home” (Bonner 200).

As the transportation infrastructure began to develop, doctors were able to widen their markets by expanding the territory they could cover. “If the railroad did not take physicians all the way to their destination, a carriage might be waiting for them when they alighted” (Star 69). Railroads also brought patients from a distance and doctors vied for residences in ideal locations in towns along rail lines. In cities, there was also an incentive for doctors to locate along streetcar routes.

Automobiles were first produced in the 1890s, and they became more reliable after the turn of the century. Doctors were among the first to buy cars. Physicians who wrote to the Journal of the American Medical Association, which published several supplements on automobiles between 1906 and 1912, reported that an auto cut the time required for house calls in half. “It is the same as if the day had forty-eight hours instead of twenty-four,” a doctor from Iowa rejoiced. (Kessel 814). The advent of the automobile industry was transforming the landscape of the United States. While only 22,000 automobiles were manufactured in the U.S. in 1904, a decade later car registration totaled more than 1 million. Gasoline, once a useless byproduct in the refinement of kerosene, quickly became the oil industry’s main product (McPhee 15).

By the mid-1920s the automobile market in the United States was becoming saturated. However, a large portion of the U.S. urban population still rode the extensive public transport networks of electric trolleys and trains. To leverage more profit GM, the largest automobile corporation in the country, diversified into other markets, including rail passenger service and busses. General Motors began to monopolize all sectors of the transportation industry. Yet automobiles returned higher profit margins than either buses or rail transport. It was in GM’s interest to see public transportation phased out. By reducing the number of busses and trains they could increase demand for their automobiles. Obviously, this was also advantageous for other automakers as well as the oil industry. More cars on the road would increase demand for gasoline (Snell).

Nowadays, we take for granted the advantages our transportation system provides. Patients can be quickly transported to healthcare centers—a few seconds can mean survival or death. “When serious injuries occur, the difference between life and death could be determined by the care a victim receives in the first ‘golden hour.’ Nowhere is that more true than on the battlefield. That’s why the U.S. military’s medical community is constantly developing technology and hardware to assure more of the wounded receive the appropriate trauma care before the golden hour is over. That includes reducing the time needed to locate the wounded warrior and evacuate him [or her] to a Mobile Army Surgical Hospital (MASH) facility” (Siuru 53).

It’s easy to miss the negative aspects when we think about how our transportation system has helped us improve quick access to healthcare. In addition, medical devices and supplies that are produced by using the byproducts of petroleum have significantly improved healthcare technology. But there is a dark side—the recent oil spill at the Deep Horizon site is a case in point. How can we promote the benefits of a healthy population if we are destroying the ecology of our planet? Health and wellness is a state of mind and body. Most would agree that apprehension about humankind’s predisposition to disregard the ecology of our planet is detrimental to a person’s mental wellbeing. Of course, when healthy ecosystems become polluted, humans suffer right along with all other biological organisms. Dianne Hales puts it this way: “You cannot separate your individual wellness from the security and health of the world in which you live.” She offers several dimensions of wellness, including environmental: “Creating a safe, healthy, supportive environment promotes wellness in its most global sense. Our fate is inevitably tied to the fate of our planet. The lifestyle choices we make, the products we use, the efforts we undertake to clean up a beach or save wetlands ultimately affect our own future” (354).

The Deep Horizon incident may go down as the worst oil spill in history, but there have been countless other spills. Table 1 and Figure 1 document only a sample of the many spills that have occurred in recent decades. Given only this small sample, the quantity of oil spilled would fill Lake Michigan. Many people have been killed in these accidents; sometimes whole crews have been lost. Clearly we must make safe drilling, recovery and transport of oil the paramount consideration for the oil industry. Safety and ecological responsibility must trump corporate profits. Fines, better inspection, market leadership concerning developing crisis-management operations that can quickly plug leaks (even at extreme depths) and more research on recovery methods to collect spilled oil are all important tools in the ecological responsibility toolbox. But, even if all this becomes reality, we are still living with blinders on.

Table 1: Some Major Oil Spills

Figure 1: Graph of Oil-Spill Volumes

Spillage is given in gallons of petroleum, based on a density of petroleum of 820 kg/cubic meter. Adapted from: Daidola, J.C. “Tanker structure behavior during collision and grounding.” Marine Technology, Vol. 32, No. 1, Jan. 1995, p. 22 (Table 1); Department of Oceanography, Texas A&M University, Oil Spills: Environmental Costs of Energy Use; Dagmar Schmidt Etkin and Jeff Welch. Oil Spill Intelligence Report. 1997 International Oil Spill Conference; Jack Devanney, Patrick Doyle, and Sisyphus Beach. Exploring the CTX Tanker Casualty Database: 2007–12 Update; Reference for Great Lakes Statistics.
* Source: http://www.pbs.org/newshour/rundown/oil-ticker/

Fossil fuels clearly represent a finite, nonrenewable resource that is quickly being depleted. When we burn petroleum and coal to fuel our transportation systems, produce electricity, and heat our homes we are destroying ancient and precious entities in the process. The particular combinations of carbon and hydrogen atoms now serving us so well as fuels were assembled some 10 million to 500 million years ago, and they have been undisturbed since that time. Once we oxidize them back into carbon dioxide and water (i.e., burn them), they are gone forever (Kraushaar and Ristinen 34).

The biodiversity crisis is “the current rapid decline in the variety of life on Earth, largely due to the effects of human culture” (Campbell et al. G3). Clearly, the tons of oil that we spill into the Earth’s oceans significantly contribute to the biodiversity crisis. But there is an even more ominous effect. When we burn fossil fuels we create greenhouse gases. Global warming is “a slow but steady rise in Earth’s surface temperature, caused by increasing concentrations of greenhouse gas (such as carbon dioxide and methane) in the atmosphere” (Ibid G11). Vast amounts of habitat, from tundra to tropical forest will be altered by global warming, resulting in the loss of many species of plants and animals—human health will be affected too. Global warming may spawn catastrophic heat waves and disease outbreaks. Less productive farms could increase food prices when demand surges due to supply shortages (Ibid 770-71).

The health of humankind and the health of the planet go hand-in-hand. The biosphere is “the entire portion of Earth inhabited by life; the sum of all the planet’s ecosystems” (Ibid G3). The relationship of humankind and the biosphere is aptly expressed by Native American traditions: Through the Great Spirit, everything is intimately connected and related to everything else. This connection is biological, spiritual, and psychic (Voss et al.). As stated previously, Hales emphasizes: “You cannot separate your individual wellness from the security and health of the world in which you live.” She describes the spiritual dimension of wellness as “[a] sense of personal security [which] enables us to focus on deeper issues. A belief in a higher value commits us to working toward the greater well-being of all people on Earth. This commitment can, at times, be illusory and very complicated. Never-the-less, as Martin Luther King, Jr. said in his address to the Southern Christian Leadership Conference in 1967, “Let us realize the arc of the moral universe is long but it bends toward justice.” Milton Nascimento’s and Fernando Bradt’s poem O Planeta Blue is appropriate because it aptly delivers the message that all is not right and that if we are to survive as a species we must learn to become a part of the natural ecosystem and not simply rob from Earth’s bounty.

The first impression of
The Blue Planet
Is not the truest vision
Beyond the color, blue is also very sad
There can be a naked side, a raw side
A dark side of blue

—Pictures of Oil Spills—

Spillage is given in gallons of petroleum, based on a density of petroleum of 820 kg/cubic meter.

Atlantic Empress

Castillo De Bellver

Amoco Cadiz

Haven

Torrey Canyon

Urquiola

Independento

Jakob Maersk

Braer

Prestige

Sea Empress

Katina P

Exxon Valdez



–Photo Credits–

Sources

Bonner, Thomas N. Medicine in Chicago, 1850–1950. Madison, WI: American History Research Center, 1957.

Campbell, Neil A., Jane B. Reece, Martha R. Taylor, and Eric J. Simon. Biology: Concepts & Connections. 5th ed. San Francisco: Pearson/Benjamin Cummings, 2006.

Hales, Diane. An Invitation to Wellness: Making Healthy Choices. Belmont, CA: Thomson Higher Education, 2007.

Kessel, George. “Would Not Practice Without an Auto.” Journal of American Medical Association 50 (March 7, 1908): 814.

Kraushaar, Jack J. and Robert A. Ristinen. Energy and Problems of a Technical Society. 2nd ed. New York: John Wiley & Sons, 1993.

McPhee, Douglas G. The Story of the Standard Oil Company of California. San Francisco: Standard Oil Company of California, 1937.

Siuru, Bill. “High-Tech Battlefield Medicine.” Electronics Now 68 (1997): 53–54. Applied Science & Technology; Readers Guide (Current Events). Wilson Web. WU Mabee Lib., Topeka, KS. 12 Jun. 2010 <http:wilsonweb.com/199709103420008>.

Snell, Bradford C. American Ground Transport: A Proposal for Restructuring the Automobile, Truck, Bus and Rail Industries. This report was prepared for the Subcommittee on Antitrust and Monopoly, Committee on the Judiciary. Washington DC: U.S. Government Printing Office, U.S. Senate, 26 February 1974.

Star, Paul. The Social Transformation of American Medicine: The rise of a sovereign profession and the making of a vast industry. New York: Basic Books, 1982.

Voss, Richard W., Victor Douvill, Alex Little Soldier, and Gayla Twiss. “Tribal and Shamanic-based social work practice: a Lakota perspective.” Social Work 44.3 (May 1999): 228(1). Academic OneFile. Gale. WU Mabee lib., Topeka, KS. 18 Jun. 2009
<http: galegroup.com/A54772595>.

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An Open Letter to a Healthcare Insurance Provider

Subject: Agent/Marketing Position Announcement

Dear Sir or Madam:

In the fall of 2009 I graduated from a nationally accredited university with a degree in business administration; my major is management.

I am very interested in the healthcare industry and believe The Patient Protection and Affordable Care Act (HR 3590) is a step forward in providing quality healthcare insurance for all Americans. The provisions in Title II of HR 3590, concerning minimum essential coverage for nearly all Americans by 2014, provide a huge opportunity for healthcare corporations. Personally, I would like to see vertical integration in the healthcare industry to give consumers a “bigger bang for their buck.” However, the characterization of healthcare as a commodity is in no sense correct.

Until we embrace social citizenship we will continue to stumble as a society in providing adequate healthcare to all our people (Fraser and Gordon). Please understand that I am not advocating socialized medicine. I believe social citizenship, as it involves healthcare, concerns many stakeholders: the pharmaceutical and medical suppliers must value compassionate care over monitory profit, potential doctors and nurses must be given financial help to allow them to reach their career goals without incurring enormous debt, healthcare providers should work toward horizontal integration to lower unit costs and provide patients more options and higher-quality care, the general public needs to become more aware of health and wellness opportunities and practice healthier lifestyles, food distributors need to provide more outlets that supply healthy food to intercity markets, restaurants (especially fast-food establishments) should provide healthy food options on their menus, and healthcare insurers should adopt the provisions of HR 3590—even before these requirements are mandated by law. Some of the conditions of HR 3590 that relate to healthcare insurance are as follows:

  • No lifetime or annual limits
  • Prohibition on rescissions
  • Coverage of preventable health services
  • Development and utilization of uniform explanation of coverage documents and standardized definitions
  • Prohibition of preexisting condition exclusions or other discrimination based on health status
  • Fair healthcare insurance premiums
  • Guaranteed availability and renewability of coverage
  • Prohibition against discrimination of individual participants and beneficiaries based on health status
  • Comprehensive healthcare insurance coverage
  • Prohibition on excessive waiting periods

If your organization embraces these values I would be very interested in talking with you. Healthcare insurance providers have a tremendous strategic opportunity. Title I of HR 3590 discuses “consumer choices and insurance competition through health benefit exchanges.” Firms that quickly embrace the provisions of HR 3590 will create brand recognition and will have a strategic opportunity as healthcare exchanges become available. Section 1312 states:

The Secretary [of the U.S. Department of Health and Human Services] shall establish procedures under which a State may allow agents or brokers—(1) to enroll individuals in any qualified health plans in the individual or small group market as soon as the plan is offered through an Exchange in the State; and (2) to assist individuals in applying for premium tax credits and cost-sharing reductions for plans sold through an Exchange.

In the very near future the role of healthcare insurance representatives and marketers will change greatly. I believe this is a very promising career path but the underlying motive for following such a career must be to provide more people access to affordable, compassionate healthcare. Any insurance provider that supports these values and helps their employees to champion these core beliefs should do well in the coming years.

Already, Section 1421 of HR 3590 offers small businesses tax credits of up to 50% if they provide their employees with healthcare insurance. By 2014 there will be a surge in demand for healthcare insurance as it becomes mandatory. Forward-looking healthcare insurance providers will have ready to use plans in place to meet the huge new demand when small businesses and individuals start using the new healthcare insurance exchanges.

The healthcare industry is not only the foundation of our economy but also the bedrock of our society. The requirements in Title II of HR 3590 improve access to Medicaid, enhance support of children’s health insurance programs, and provide many other measures that improve access to quality healthcare. Yet, it is unlikely we can achieve the renaissance in compassionate care that is at the core of HR 3590 unless there is a corresponding change in healthcare values throughout our culture. Jami Rubin, a healthcare investment researcher said, “[e]conomic cycles have minimal effects on the drug industry. Illness is not affected by economic factors, and drug companies tend to do well regardless of the state of the global economy” (38). Many would disagree with Rubin’s conclusions. During the Great Depression the combination of unemployment, underemployment, and reduced pay debilitated the standard of living of most Americans. Undoubtedly, these forms of deprivation did not lead to good health. Homelessness became widespread and many people did without heat or utilities. Migratory workers were poorly fed and many lacked shelter. Malnutrition became commonplace, and starvation befell many. Family disruption and loss of self-respect plagued the unemployed; many remained out of work for years. The grim situation also forced many to leave behind their standards of dignity. Begging, thievery, and prostitution became the way to get by for a large number of Americans. Those who were fortunate enough to keep their jobs faced unbearable working conditions, which led to chronic anxiety and constant stress. All these factors escalated the risk of physical and mental illness during the Great Depression (Kusmer; Markowitz). Recent times have reminded us of what happened in the 1930s. In the Great Recession many laid-off workers have lost their healthcare coverage, their homes, and their standard of dignity.

It is understandable that research, motivated by competition, is extremely important in bringing to market new, innovative pharmaceuticals, healthcare devices, and therapies. Unfortunately, some firms seem to have lost all understanding of the ethical implications of healthcare. Quick profits trump long-term sustainability and result in the public losing confidence in the American healthcare system. Compassionate healthcare delivery is left out of the equation. For example, recently AstraZeneca was fined $520 million for attempting to market its anti-psychotic drug Seroquel to doctors that treat health problems unrelated to what the drug was designed to be used for (Sutton).

Competition is important for pharmaceutical companies, healthcare insurance corporations, and healthcare providers. But should the underlying, essential goal of compassionate healthcare be sidelined in favor of quick monetary rewards? Perhaps more could be achieved if the healthcare industry were consolidated. Many investors would benefit if healthcare conglomerates became solid, long-term investments; instead of speculative, haphazard adventures. If this were the case perhaps a more stable industry would better support economic growth and innovative, worthwhile research. Moreover, the industry could become a source of stability during recessions and economic downturns; not just for investors but for Americans of every socioeconomic stripe.

I am sure you agree that, as a letter of introduction, my correspondence is unconventional. My goal is to give you a sense of my understanding and commitment to healthcare reform. If you honestly believe your organization is taking, or will soon take a leadership role to embody the principles of HR 3590 in your corporate culture, I would be very interested in talking with you.

Very Sincerely,

Leslie Charles Coover

References

Fraser, Nancy and Linda Gordon. “Contract versus Charity: Why Is There No Social Citizenship in the United States?” Socialist Review 22 (1992): 45-47.

Rubin, Jami. “Pharmaceutical Industry Dynamics.” Industry Analysis: The Health Care Industry. Ed. James Balog. Washington, DC: Association for Investment Management and Research, 1993: 38 (quotation), 38-50.

Kusmer, Kenneth. Down and Out, on the Road: The Homeless in American History. New York: Oxford University Press, 2002: 193-220.

Markowitz, Gerald and David Rosner, eds. “Slaves of the Depression.” Workers’ Letters about Life on the Job. Ithaca: Cornell University Press, 1987.

Sutton, Stephanie. “AstraZeneca fined $520 million for off-label marketing.” PharmaTech.com
http://pharmtech.findpharma.com/pharmtech/News/AstraZeneca-fined-520-million-for-off-label-market/ArticleStandard/Article/detail/667219?contextCategoryId=35097 .

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American Healthcare Roots: Isidore Sydney Falk

By Leslie Charles Coover

Isidore S. Falk (1889-1984)

I.S. Falk was born in Brooklyn, New York in 1899. In 1915 he became a laboratory assistant to Charles-Edward Amory Winslow, the Professor of Public Health at Yale Medical School (Roemer).

1915-29

In 1923 Falk earned a Ph.D. at Yale in public health, working in immunology and bacteriology. He taught hygiene and bacteriology at the University of Chicago from 1923 to 1929, becoming a full Professor (Ibid).

1929-35

In May 1927 eight philanthropic foundations created the Committee on the Costs of Medical Care (CCMC). In the early 1930s, Falk was recruited by Winslow to head the research staff at the CCMC. Although Dr. Falk was trained in bacteriology and immunology, he was deeply committed to the idea of universal healthcare coverage (Derickson, Health). In 1932 Falk authored a report with fellow staff members Refus Rorem and Martha Ring. The report provided conclusive evidence of empty hospital beds “while millions suffer and tens of thousands perish for lack of care” (Falk et al.).

The CCMC could not come up with a plan that would make healthcare available to everyone. There was much debate; ultimately, two main factions emerged: The majority backed voluntarism (i.e., private insurance) and community health centers as a way to work toward universal healthcare coverage (Derickson, Health).

The two most controversial recommendations in the majority opinion were that groups of physicians be organized, preferably around a hospital, and the costs of medical care should be shouldered by voluntary, group-insurance (Roemer). When the CCMC released its majority opinion, the American Medical Association (AMA) unleashed a furious public attack. An editorial in the December 3, 1932 issue of the Journal of the American Medical Association assailed the CCMC’s proposal for universal healthcare as an “incitement to revolution,” and called the committees backing of universal healthcare insurance “utopian fantasies” (Editorial, The Committee). Eight days after the CCMC issued is majority opinion, American voters elected Franklin D. Roosevelt to the presidency. In 1932, the year FDR was elected, Albert Milbank was the chairman of the board of the Borden Company. One of Milbank’s philanthropic activities was the Milbank Memorial Fund (MMF). The MMF was determined to use the work of the CCMC as a platform for a bold new healthcare initiative. In early 1933, Milbank predicted that the voluntary approach promoted by the CCMC would fail. He argued that compulsory insurance, organized on at least a state level, was what was needed to achieve universal coverage (Derickson, Health).

Falk worked closely with the MMF and on March 14, 1934 he sent a report to MMF advisors. He argued that a “growing public demand for more and better medical care” was becoming evident. He discerned an “increasingly impatient” public (Falk, Report). Two months later Falk stressed the unpredictability of medical expense was the culprit. He believed the problem could be best handled through group insurance (Falk, Formulating).

In June of 1934 FDR created the Committee on Economic Security (CES). Healthcare reform faced an uphill battle. Falk and Edgar Sydenstriker fought hard to make health protection a primary part of reform. However, from the outset they realized both President Roosevelt and the chair of the CES, Secretary of Labor Francis Perkins, were skeptical of healthcare reform. This was mainly due to the influence of the AMA and its allies. Opposition from these all-powerful interests could sink the whole social security plan (Derickson, Health).

Ultimately, healthcare reform became the sacrificial lamb. Falk and Sydenstriker presented the CES with a supplemental report. They urged that New Deal legislation, which was already under consideration, include a healthcare insurance section. The supplemental report was suppressed and Congress never discussed it (Ibid). In the early 1930s, the application of insurance to medical costs was a strange and fearful idea (Roemer).

Perhaps the Milbank Memorial Fund could have been more influential in getting healthcare reform on the New Deal agenda if it had mobilized grassroots support. But it did not—the outcome was disastrous. Medical opponents mounted a boycott of the infant formula and other products manufactured by the Borden Company. In March 1935, the MMF acquiesced and withdrew from the healthcare debate (Derickson, Health).

1936-1953

In 1936, Falk became the Assistant Director of the Bureau of Research and Statistics (BRS) of the brand-new Social Security Board, which later became the Social Security Administration. Two years later, in 1940, Falk became the Director of the BRS (Roemer). Unlike some union and civil rights advocates, Falk and other Social Security officials tried to avoid rights-rhetoric in favor of “the dry statistical language of needs assessment” (Derickson, Health).

Less than a month after Japan’s surrender, President Truman proposed an economic Bill of Rights, which included a “right to adequate medical care and the opportunity to achieve and enjoy good health” (Harry Truman). Truman advocated for universal healthcare insurance and Robert Wagner and James Murray in the Senate, and John Dingell in the House of Representatives, introduced a bill devoted exclusively to healthcare reform (a bill that was drafted largely by Falk) (Roemer). Partisan skirmishing began immediately. The Journal of the American Medical Association denounced the Wagner-Murray-Dingell Bill as an apocalyptic threat: “Let the people of our country realize that the movement for the placing of American medicine under the control of the federal government through a system of federal compulsory sickness insurance is the first step toward regimentation of utilities, of industries, of finance and eventually of labor itself” (Editorial, The President’s).

In November of 1946 the Republican Party won control of both houses of Congress. In hearings beginning in 1947 the Senate interrogated any federal official associated with healthcare reform. “Considerable witch-hunting preceded Senator Joseph McCarthy’s rampages of the early 1950s” (Derickson, The House). Marjorie Shearon, who had been one of Falk’s subordinates at the Social Security Board, mounted a scathing attack on her former boss. She claimed Falk was an evil and powerful genius who directed a plot to impose a “national medical service, . . . such as they have in Russia” (Taft).

Falk, Wilbur Cohen, and other Social Security administrators underwent grueling marathons of cross-examination during the summer of 1947 and the winter of 1948. In the dark mood of the Cold War, any vague, unfounded assertion of unpatriotic behavior received lengthy congressional attention. But the conservative offensive went far beyond notions of communist agitation. The possibility that healthcare insurance would extend to large numbers of African-Americans fueled the fires of white supremacist racial bigotry. The likelihood that federal healthcare insurance legislation would prohibit discrimination in the delivery of healthcare intensified the paranoia of southern conservatives (Derickson, Health).

Falk consistently advocated only mild liberalism. He sought modest redistribution of wealth (if any) under cautious forms of contributory healthcare insurance. Yet, his critics even stooped to xenophobic ramblings to demonize the man. A November 1947 article in Medical Economics entitled “The Man behind the Wagner Bill,” described Falk as “satanic, but . . . only because of hair above each temple” (The Man). I.S. Falk was Jewish. The unnamed author was clearly invoking the “medieval anti-Semitic image of the Jew as a horned, goatlike creature” (Derickson, The House).

It is noteworthy that domestic corporations and fledgling multinational enterprises played a major role in the anti-reform assault. Physicians enjoyed the active support of big business. Organizations that played a major role in blocking healthcare reform included “the National Industrial Conference Board, the US Chamber of Commerce, the American Enterprise Association, and executives of individual firms. The National Industrial Conference Board, not the American Medical Association, sent Marjorie Shearon to the Senate Republicans” (Ibid).

With the election of Dwight D. Eisenhower in 1952 a comprehensive national healthcare insurance plan seemed hopeless. Falk drafted a proposal for healthcare insurance that was limited to aged Social Security beneficiaries. A few years later it was introduced in Congress. After several revisions, in 1965, it became Medicare. In the winter of 1953, with the new political environment unfriendly to social legislation, Falk resigned from government service. (Roemer).

1954-1961

Dr. Falk served as an independent consultant on various health service and planning organizations during this period of his life. This included assignments in Malaya, Singapore, and Panama, but he mainly worked with the United Steel Workers of America on union healthcare programs (Ibid).

1961-1984

Dr. Falk returned to New Haven in 1961, this is where his career in healthcare started. From 1961 to 1968 he served as a professor at the reorganized Yale Department of Epidemiology and Public Health. When he retired, he became the Executive Director of a Community Health Center Plan, which began operation in 1971. This plan became the first health maintenance organization (HMO) in the nation under the 1973 Federal HMO Act (Ibid).

In an article in the American Journal of Public Health, Milton Roemer wrote, “On October 4, 1984 the American movement for national health insurance lost its most profound analyst and most eloquent advocate, when the life of I.S. Falk came to an end. In the more than half-century of work of I.S. Falk, one finds a remarkably accurate reflection of the social battles surrounding efforts to achieve a program of economic support to make essential health services available to the entire United States population” (Ibid).

Dr. Falk did not live to see the passage of The Patient Protection and Affordable Care Act (HR 3590), which was signed into law by President Obama on March 23, 2010. Nonetheless, many of the provisions in this act were goals he fought all his life for. The crucial elements of HR 3590 remind us of Falk’s consistency of vision and his “formidable, disciplined, crusading rationalism. He remained a consummate scientist in his passionate dedication to knowledge, his awesome research abilities, and his willingness to draw conclusions from the facts, even when these were politically unacceptable” (Stevens). He knew that the power of knowledge is what brings change.

Sources

Derickson, Alan. Health Security for All: Dreams of Universal Health Care in America. Baltimore: The Johns Hopkins University Press, 2005.

Derickson, Alan. “The House of Falk: The Paranoid Style in American Health Politics.” American Journal of Public Health 87.11 (Nov. 1997): 1836-1842.

Editorial. “The Committee on the Costs of Medical Care.” JAMA 99 (1932).

Editorial. “The President’s National Health Program and the New Wagner Bill.” JAMA
129 (1945): 950.

Falk, I.S., C. Rufus Rorem, and Martha D. Ring. The Costs of Medical Care: A Summary of Investigations on the Economic Aspect of the Prevention and Care of Illness. Chicago: University of Chicago Press, 1933.

Falk, I.S. “Formulating an American Plan of Health Insurance.” AALR
1934.

Falk, I.S. “Report to the Round Table on Medical Care.” Mar. 14, 1934.

Harry Truman to Congress, Sept. 6, 1945. Congressional Record. 91 (1945): 8368.

Roemer, Milton I. “I.S. Falk, the Committee on the Costs of Medical Care, and the Drive for National Health Insurance.” AJPH 75.8 (Aug. 1985): 841-848.

Stevens, Rosemary. “I.S. Falk and the Challenge of Facts.” AJHP 75.8 (Aug. 1985): 827-828.

Taft Papers, box 805, folder, Social Security-National Health-Marjorie Shearon, 1948.

“The Man behind the Wagner Bill.” Medical Economics (Nov. 1947): 47.

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Human Capital and the Healthcare Industry

By Leslie Charles Coover

Human capital is made up of the physical and mental abilities of employees that contribute to productivity (Garibaldi). Human capital is the foundation of intellectual capital, which includes such things as an organization’s reputation, the loyalty and commitment of its employees, the quality of customer relationships, organizational values, and brand names (Dess et al.).

One, if not the most important human capital resource in the healthcare industry is the primary caregiver. Because primary care physicians are the main link in the patient-doctor relationship, the supply of this valuable resource is essential if the healthcare industry is to succeed in meeting the needs of all Americans. Primary care physicians often are family doctors. They have played a vital role in shaping the reputation, quality of relationships, and cultural values of our healthcare system. When most Americans think of their family doctor they have an image of a caring, compassionate care giver who has a great deal of medical training and experience in the field of medicine.

When potential future doctors, nurses, and medical technicians consider their career paths they determine whether expected benefits exceed costs. Although they will probably be greatly influenced by intrinsic motivation (e.g., the opportunity to help people), from a purely practical perspective they determine if the present value of their income stream less the present value of costs merits the investment in time, money, and commitment.

Jason Plautz addressed the issue of shortages in the supply of primary care givers. “The American Academy of Family Physicians estimates that by 2020, the patient load will require 40,000 more doctors than will be practicing.” Many worry that expanding coverage under the Patient Protection and Affordable Care Act (HR 3590) and healthcare reconciliation (HR 4872) will worsen the problem.

According to Lauran Neergaard, a reporter for the Associated Press, “primary care physicians already are in short supply in parts of the country.” This quintessential element in the fabric of healthcare is “losing out to the better pay, better hours and higher profile of many other specialties.”

The need to address the issue of primary health care providers was not missed by the framers of the recent healthcare reform bills. Title V of HR 3590 addresses the human capital needs of the healthcare industry. One of the goals is to increase the supply of qualified healthcare workers to improve access to and delivery of “health care services for all individuals” (p.1244). To accomplish this objective Title V spells out measures to enhance “health care workforce education and training” (1245).

Section 5002 defines a Health Care Career Pathway as “a rigorous, engaging, and high quality set of courses and services that . . . is aligned with the needs of healthcare industries” (1246). The term “‘physician assistant education program’ means an educational program in a public or private institution in a State that . . . has as its objective the education of individuals who, upon completion of their studies in the program, may be qualified to provide primary care medical services with the supervision of a physician” (1249).

Section 5102 establishes grant programs to “analyze State labor market information in order to create health care career pathways for students and adults, including dislocated workers” (1277). Most of the grant funds must be used “to promote innovative health care workforce career pathway activities, including career counseling, learning, and employment” (1282). The amount of planning and implementation grants for the year 2010 is $158 billion, and such sums may be allocated “for each subsequent fiscal year” (1285).

Sections 5203 and 5204 address health care workforce loan programs. Loans of up to $35,000 a year will be awarded to people pursuing degrees in healthcare who agree “to work in, or for a provider serving, a health professional shortage area or medically underserved area” (1299). If healthcare workers who have completed their degrees agree to serve in “the full-time employment of a Federal, State, local, or tribal public health agency,” (1302) in some cases for no more than three years, loans will be forgiven.

Other provisions of HR 3590 that will help increase the supply of primary care givers are found in Section 5207, which funds the National Health Service Corps Loan Repayment Program. This program repays up to $50,000 of a student loan for primary care medical, dental and mental health clinicians in exchange for 2 years of service in a Health Professional Shortage Area. Upon completion of service, clinicians may be eligible to apply for additional help in exchange for extended service.

Section 5208 funds “the development and operation of nurse-managed health clinics” (NMHCs) (1309). “The term ‘nurse-managed health clinic’ means a nurse-practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vulnerable populations and that is associated with a school, college, university or department of nursing, federally qualified health center, or independent nonprofit health or social services agency” (1310).

The Secretary of Health will award grants to qualifying NMHCs. Fifty million dollars has been appropriated for fiscal year 2010 and additional amounts may be provided for the years 2011 through 2014 (1312).

One amendment to Title V (Health Care Workforce) lays a blueprint to develop a plan of action to eliminate “the barriers to entering and staying in primary care, including provider compensation” (2328). Another amendment authorizes the Secretary of Health to set up programs and provide additional grants to provide one-year training for nurse practitioners to prepare them for careers in federally qualified health centers (FQHCs) and NMHCs (2332).

Finally, Rural Physician Training Grants will be awarded to medical schools across the country to establish programs that will help train “home-grown” doctors with a real personal interest in the health of their community (2344). This is yet another provision designed to overcome one of the biggest barriers to health care in rural communities—the shortage of doctors, particularly primary care practitioners.

A brief look at the history of the American healthcare system may shed some light on the implications of the latest initiative. Medical education in the nineteenth century was usually brief and undemanding—physicians were numerous (Ludmerer). John Hopkins was the first medical school that required a college degree for admission; this policy was adopted in 1893. With the advent of the twentieth century, there was a growing optimism about the value of scientific medicine. Advancements in biomedical science made many people hopeful (Howell). Advances in diagnostic technology, surgical methods, and other medical practices gave patients, regardless of their economic status, reason to seek access to sophisticated care. As providers began to curtail free services, due to the increased cost of career development, technology, and other operating costs, the patients with modest or meager incomes frequently became the ultimate casualty of a consumer society.

Frequent attempts have been made for over 100 years to remedy the problem. Some advocates have proposed public medicine initiatives. At the other end of the ideological spectrum, others have promoted methods of achieving reform where the government has no role. Between these two extremes there have been hoards of plans that mix public and private forms of both insurance and care. The failure of these plans has resulted in many missed opportunities, including:

  • Doctors that leave the primary care field or who no longer accept Medicaid or Medicare patients,
  • Patients that can’t find healthcare providers, and
  • Students who choose other career paths due to the bureaucracy-hurdles that they cannot overcome.

Increasing the number of primary care providers is one substratum of the HR 3590 and HR 4872 bills. Hopefully the help will get to where it is needed and not just result in more fruitless studies and needless layers of bureaucracy.

Sources

Dess, Gregory G., G.T. Lumpkin, and Alan B. Eisner.Strategic Management. 3rd ed. Boston, MA: McGraw-Hill, 2007.

Garibaldi, Pietro. Personnel Economics in Imperfect Labour Markets. New York: Oxford University Press, 2006.

Howell, Joel. Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century. Baltimore: John Hopkins University Press, 1995.

Ludmerer, Kenneth. Learning to Heal: The Development of American Medical Education. New York: Basic Books, 1985.

Neergaard, Lauran. “Health Overhaul Likely to Strain Doctor Shortage.” Associated Press March 28, 2010. New York Times Article Archive. 1 Apr. 2010.

Plautz, Jason. “Are There Enough Doctors To Make Reform Work?” National Journal (2009). Academic OneFile. Gale Document Number: A212589179. 1 Apr. 2010.

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