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conclusion conclusion Working to confront the debilitating diseases that plagued the Southern United States during the first decades of the twentieth century, officials from the United States Public Health Service built the foundations of the federal government’s modern role in public health. Beginning with the nation’s mobilization for World War I, PHS officers assembled a political coalition on the basis of their ability to deliver effective services and to frame these services as necessary for the South’s economic development. During the New Deal, the bonds they forged with political leaders and communities provided the basis for an expanded national government role in helping to ensure the health of Americans through population -based efforts. Ultimately, the threat of disease during wartime and solid Southern support led to the emergence of the PHS’s Atlanta-based Communicable Disease Center, later renamed the Centers for Disease Control and Prevention. While the national government established an overt and central position in public health, the United States rejected a comparable or linked national government role in the realm of individual medicine. Divisions among key policy makers over both policy and strategy were central to this outcome, as were interest group alignments, political institutions, and timing. Had federal policy makers pursued compromise with organized medicine in either 1935 or 1938, the United States might have gone down an entirely different path in the realm of health policy. Large-scale government intervention in facilitating access to individual medical services for the indigent, in building infrastructure, and in facilitating access to expensive treatments for lower- and medium-income Americans, under the approach advocated by Thomas Parran, might have preceded the emergence of widespread access to insurance through employer-sponsored plans. As a result, physicians might have found themselves negotiating for higher reimbursement rates or for changes in the developing system rather than arguing that voluntary insurance was succeeding in addressing the nation’s health-financing problems . If created, employer-sponsored plans might have served as a supplement to the emerging system. Notably, the approach advocated by Parran and the PHS would have obligated the federal government to help foot the bill for the chronic diseases that helped fuel the growth of health costs in the decades that followed. 196 : CONCLUSION The path-dependent nature of policy development strengthened the role of public health institutions during the New Deal and World War II, but the critical juncture of the 1930s and 1940s led to a far different outcome for federal intervention in individual medical services. After a period of fluidity, the emergence of the conservative coalition (and its strengthening after the 1938 midterm elections) combined with mobilization for World War II to foreclose once-plausible policy options. As the PHS continued to expand its role in American public health, federal wage and tax policy helped to fuel the growth of employer-sponsored health insurance. Over time, the creation of a system intended to integrate public health and individual medicine became increasingly unlikely. As employersponsored health insurance grew, constituencies such as organized labor, business, the AMA, and the insurance industry adjusted their expectations and strategies. In the years after Thomas Parran’s ouster from the position of surgeon general, the PHS almost completely abandoned the approach to health policy articulated by Parran and men such as Joseph Mountin (who died in 1952). By the mid-1960s, the divided national health policy regime that began to emerge in the 1930s was firmly entrenched. Continuity and Change in American Health Policy The bifurcated health policy regime that emerged out of the 1930s and 1940s proved highly resilient. Despite hopes that Medicare might provide the framework for a more universal system, widespread access to insurance through tax-preferred employment-based plans and the ongoing growth of medical costs made building a political coalition in favor of national health insurance proposals difficult. Increasingly, organized labor and the insurance industry emerged as pivotal interest groups in debates over insurance. While successful collective bargaining ensured that union members were generally able to access medical care through employer-sponsored insurance , and Medicare addressed the issue of insurance after retirement, many union leaders continued to hold out hope for a single-payer system based on the Canadian model. Insurers, for their part, had a clear material interest in fighting any government-backed approach that might negatively impact their market position. By the early 1970s, the ongoing growth of medical costs and gaps in coverage within the nation’s health insurance system were...


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