Teaching Hospitals and the Urban Poor (review)

Teaching Hospitals and the Urban Poor. By Eli Ginzberg. New Haven:Yale Univ. Press, 2000. Pp. 129. $20.

In this condensed analysis of American health policy during the past half century, Eli Ginzberg, a noted health economist at Columbia University, focuses on developments since the end of World War II, paying particular attention to the fate of prominent academic health centers. He also examines their relationship with the so-called "urban poor," a group he defines as individuals with incomes near the federal poverty level, some eligible for Medicaid but mostly without any health insurance. Printed in a small format, this 100-page text has no footnotes and only a selected bibliography. In past decades, the topic has received plenty of attention from a cadre of distinguished authors representing various fields of study, from politics to economics, history to sociology, and has been aptly summarized by Pulitzer Prize winner Paul Starr in his widely read The Social Transformation of American Medicine (1982). Ginzberg's approach is to briefly glance at the past, examine the present in terms of prior developments, and then venture a series of short-term forecasts based on the available evidence.

In this fascinating evolution of the American medical system, two critical years loom large: 1965 and 1983.The former coincided with enactment of the Medicare program, the federal government's most comprehensive entry into the health care field, while the latter signaled the passage of legislation designed to curb its expenditures through fixed payment rates using "diagnosis-related groups" (DRGs). Readers should not, however, expect a detailed and nuanced exposition. Absent is Starr's strategy of also showing the "roads not taken" since the 1960s.Yet Ginzberg lucid synthesis will be of interest to those who would like to delve into the basic complexities and vicissitudes of our health care system. His proven scholarship and decades-long experience endow many of his predictions with an uncanny certainty and have made him increasingly a primary source. In my recent book Mending Bodies, Saving Souls: A History of Hospitals (1999), I describe Ginzberg's 1983 visit to my institution, the University of California at San Francisco. Addressing our Board of Overseers, he flatly announced that the love affair between the American public and medicine, born after World War II, was over. Even though UCSF was surrounded by an affluent community base and small indigent, Ginzberg warned that the institution would be financially threatened unless it could rethink its academic and assistential mission. Nearly 20 years and a failed merger with Stanford later, his assessment has been short of prophetic.

After a brief introduction, the author successively presents the effects of the Second WorldWar on medicine, especially the positive perception of the military health care system by nearly 20 percent of the population who served their country during that global conflict. Together with an expansion of medical insurance plans, federal support for biomedical research, and funds for local hospital construction, the postwar period can be seen the launching pad for what historians have called American medicine's "golden age." The next chapter deals with the birth of Medicare and its long-term effects on academic medical centers and the hospital industry at large. Nourished by a generous reimbursement program and coverage of capital costs, American hospitals experienced a dramatic expansion of their facilities and staffs. Clinical professors, residents, and fellows contributed to the explosive growth of specialists providing tertiary care. Unfettered by fiscal restraints, medical schools, in turn, doubled in numbers. The sick poor, a population that in the name of charity had historically served as hospital research and teaching material since the Enlightenment, was replaced by an insured middle class.

Subsequent chapters discuss the myths and realities surrounding the American physician supply, as well as the challenges that confronted academic health centers since the 1980s. Among them were the unmet health needs of their neighboring poor. Another section succinctly explains the impacts of managed care, before...