Health Care for Some: Rights and Rationing in the United States Since 1930 by Beatrix Hoffman (review)

Health Care for Some is ambitious, well-researched, and clearly written. It traces rationing and rights in the U.S. health-care system over the last eighty years in four phases. The first describes the access crisis created by the Great Depression and the failure to include health security in the enactment of Social Security. The second traces the piecemeal efforts to provide health care through pubic initiatives during World War II, the preservation of hospital autonomy with federal Hill-Burton funding in the postwar years, and the growth of private health insurance. The third phase traces the efforts to expand entitlements if not rights between 1965 and 1980. The final phase, 1981 to 2008, explores the efforts to control cost and privatize insurance, the growth of the uninsured and their burden on hospital emergency departments and, finally, the still unresolved struggle to implement the Affordable Care Act of 2010.

The book chronicles all of this with rich, painful anecdotes documenting a rationing system based on privilege, in spite of periodic rhetoric about rights. The anecdotes reveal a system far more brutal than any of the more formalized rationing systems so disparaged by critics of our periodic efforts to assure more universal access to care. It is an unrelenting indictment. A child of a family on relief in the 1930s dies because of a ruptured appendix unable to get prompt attention from a charity clinic. Hospitals in the 1940s into the 1960s receiving federal funding from the Hill-Burton Act of 1946 protected their right to deny care to the indigent and blacks despite vague assurances in the Act. Black mothers in labor and victims of automobile accidents were refused emergency treatment because of their race, resulting in deaths, particularly in the South. The dumping or transferring of indigent patients from hospital emergency rooms to safety net hospitals persists and in some cases produces the same results.

Why did the United States fall so far behind other developed countries in assuring a right to universal access to care? Part of the reason, Hoffman acknowledges, is the pervasive anti-government, private market ideology that shifted approaches away from a public social insurance model to a private commercial insurance model. This was abetted by the medical profession and nonprofit hospitals that embraced this ideology as a way to protect their own autonomy while benefiting from an expanding flow of public dollars. The result is a privatized, fragmented system restricted from better coordination of care by antitrust and anti-kickback laws necessary to control abuse by the free market entities this transformation created.

The expansive ambition of this account loses sight of some important details. The explicit rationing system involved in organ procurement is dismissed in the preface but deserves more expanded treatment in a book that deals with all of the other forms of rationing that have taken place in the United States. Once the choice was made to prohibit the sale of organs and rely on voluntary anonymous gifts, the system has worked quite well and deserves to be compared with the more informal ways that treatment is rationed. The account of the development of the Title VI prohibition against the distribution of federal funds to organizations that discriminate on the basis of race in the implementation of the Medicare program misses the impact that precedent had on the broader use of such requirements by the federal government in transforming health care and society as a whole.

The major limitation of the book is that it leaves the impression that not much has changed. More attention to the statistical evidence would have helped provide context to the anecdotal accounts. Even the most superficial review of the numbers suggests a good deal of progress. In the early 1930s the Committee on the Costs of Medical Care reports documented for all forms of health care...