Doctors and Reformers: Discussion and Debate over Health Policy, 1925-1950 (review)

Jonathan Engel uses archival sources to add useful detail to the familiar story of the several failures to enact universal health insurance in the United States during the second quarter of the twentieth century. However, he seems not to have assessed the literature on the subject in history and adjacent disciplines; as a result, he asserts presentist conclusions rather than seeking to revise previous accounts.

Engel's book includes fresh evidence about key events in the politics of health policy from the late 1920s until the early 1940s. He offers the most thorough account to date of political factions within organized medicine; of the flailing and frustration of the small group of New Deal officials and their external allies who tried to subvert Franklin D. Roosevelt's decision that health insurance reform was not a presidential priority; and of the first attempts in Congress to enact legislation for such reform. This reviewer can attest to the thoroughness and accuracy of Engel's account of the ill-conceived advocacy of his predecessor, John Kingsbury, and members of the staff of the Milbank Memorial Fund on behalf of compulsory health insurance.

Engel makes numerous errors, however. For instance: S. S. Goldwater was never surgeon general of the United States (p. 20); Albert G. Milbank was neither the nephew (p. 24) nor the son (p. 57) of the donor of the Milbank Memorial Fund (he was a cousin); and Senator Henry Cabot Lodge never came close to being a Democrat (p. 179). In a single paragraph (p. 280) about British health policy, Engel describes a National Health System (instead of Service) that "expanded" a "35 year old national hospital service" (which did not exist), and purchased the "private practices" of general practitioners in order to nationalize them (GPs remain private practitioners).

Finally, Engel distorts the past by reading into it his opinions about the health sector today. He claims, for example, that "only in the past ten years, with the broad interjection of managed care . . . is the general public beginning to understand the prescience of" Morris Fishbein's warning against letting "any third party come between doctor and patient" (p. 16). Similarly, he concludes that critics of governmental financing of health insurance in the 1930s and 1940s "have been proven correct in their gloomy forebodings about the nature of bureaucratized care" (p. 314). Moreover, he asserts that the "most significant result of the decades of debate was the fundamental lack of systematization that defined (and continues to define) U.S. medical care" (p. 311). Such comments ignore enormous changes during the past three-quarters of a century in biomedical science and life expectancy, as well as in the size, organization, and cost of the health sector.