New Deal Medicine: The Rural Health Programs of the Farm Security Administration (review)

Michael R. Grey. New Deal Medicine: The Rural Health Programs of the Farm Security Administration. Baltimore: Johns Hopkins University Press, 1999. xvii + 238 pp. Ill. $42.50.

In a brief but compelling monograph, Michael Grey, who is both a practicing physician and a historian of medicine, attempts to give the medical programs of the Farm Security Administration (FSA) their "historical due" (p. 168). Not only does he detail the development of health-care cooperatives and other forms of prepaid health plans in rural America that defined the FSA's medical program in the late 1930s and early 1940s, he also highlights the ways in which these programs anticipated later developments in group practice and problems in the delivery of managed care.

Although the FSA health plans were highly local in nature and covered only specific, predominantly rural counties, they nonetheless reached more than half a million people at their height in 1942. The contents of these plans differed from place to place in ways that reflected the accommodations that the FSA made with local medical societies and the target populations. Some of the plans were aimed at migrant workers; others focused on the indigent members of the agricultural community (which is to say, nearly all members of that community). Still, all of the plans emphasized preventive health services and experimented with the use of nurses and other allied health professionals in the delivery of care.

But all of the plans, it seemed, required a substantial subsidy from the federal government in order to survive. Agricultural workers in such places as California's Imperial Valley or southern New Jersey's vegetable fields simply did not have enough money to form true health cooperatives. When prosperity returned and the political climate of the nation turned more conservative, the Farm Security Agency enjoyed less political support in Congress and among local physicians than before; it went out of existence by 1947.

Yet the agency left behind a substantial legacy in the health-care field. Many of the FSA officials transferred to the United Mine Workers Welfare and Retirement Fund, a prototype for union-run health-care plans in the postwar era. Other FSA officials, such as George Silver and Solomon Axelrod, emerged as professors of public health in important academic settings and influential advocates, first for national health insurance and later for Medicare.

Grey does a particularly good job in describing the local health plans, and in locating the FSA plans in the history of prepaid group health. As a modern practitioner, he is able to see the origins of modern problems in past practice. For example, when the FSA and the earlier Resettlement Administration relied upon a capitated payment scheme to pay health providers, they discovered that physicians released patients from the hospital sooner than they did in fee-for-service plans. The book's limited scope and muted tone are also refreshing. Here one finds less of the common lament about the limited nature of America's welfare state and more about the accomplishments of a particular New Deal agency. Organizations such as the American Medical Association receive more even-handed treatment here than they do in most accounts of topics related to national health insurance. Grey realizes that the AMA did more than manipulate public opinion: it also tapped into deeply held American values. Similarly, gender and race do not consume the author as they do many contemporary writers on social welfare history; instead, he realizes that the key division that defined the Farm Security Agency was that between urban and rural America.

If the book has faults, they lie in the descriptions of programs outside the immediate orbit of the FSA. For example, Grey mistakenly puts the date of the Committee on Economic Security at 1933, not 1934, and he seems not to realize that public health authority Edgar Sydenstricker...