Beginnings Count: the Technological Imperative in American Health Care [Hardcover]

David J. Rothman (Author)

Book Description

Publication Date: January 15, 1997 | ISBN-10: 0195111184 | ISBN-13: 978-0195111187 | Edition: 1

In the wake of the recent unsuccessful drive for health care reform, many people have been asking themselves what brought about the failure of this as well as past attempts to make health care accessible to all Americans. The author of this original exploration of U.S. health policy supplies an answer that is bound to raise some eyebrows. After a careful analysis of the history and issues of health care, David Rothman concludes that it is the average employed, insured "middle class"--the vaguely defined majority of American citizens--who deny health care to the poor.
The author advances his argument through the examination of two distinctive characteristics of American health care and the intricate links between them: the ubiquitous presence of technology in medicine, and the fact that the U.S. lacks a national health insurance program. Technology bears the heaviest responsibility for the costliness of American medicine. Rothman traces the histories of the "iron lung" and kidney dialysis machines in order to provide vivid evidence for his claim that the American middle class is fascinated by technology and is willing to pay the price to see the most recent advances in physics, biology, and biomedical engineering incorporated immediately in medical care. On the other hand, the lack of a universal health insurance program in the U.S. is rooted in the fact that, starting in the 1930s, government health policy has been a reflection of the needs and concerns of the middle class. Playing up to middle class sensibilities, the American presidents, Senate and Congress based their policy upon the private rather than the public sector, whenever possible. They encouraged the purchase of insurance based on the laws of the marketplace, not provided by the government. Private health insurance and high-tech medicine came with a hefty price, with the end result that about 40 million Americans could not afford medical care and were left to fend for themselves. The author investigates the moral values underpinning these decisions, and goes to the bottom of the problem of why the United States remain the only developed country which continually proves unable to provide adequate health care to all its citizens.

Editorial Reviews

From The New England Journal of Medicine

Rothman's book is an engaging, interesting, and complex one, easy to read, more difficult to evaluate. It is most obviously a collection of essays on what the author calls "decisive moments in the evolution of American public policy and public attitudes." There are six such moments, whose "tales," Rothman notes, cover "critical innovations" in the history of health insurance and medical technology. Each of the resulting six chapters takes up one of these "decisive moments." Those on health insurance deal with the origins and growth of Blue Cross, the enactment of Medicare, and the (failed) reform effort of President Bill Clinton. The technological tales deal with the origins and importance in American medical history of the iron lung, the dialysis machine, and the respirator. Each of these tales is vividly told, buttressed by documentary evidence from the period, and forcefully communicated -- with the message that these are "not case studies as such" but, rather, "intensive analyses of major turning points" in the history of the provision and financing of American medical care, and of attitudes toward it.

It is precisely the claim of explanatory power for the tales that raises the most profound questions about Rothman's work. The episodes are enormously interesting on their own. Rothman has conveyed superbly how the leaders of Blue Cross justified their version of private social insurance as a barrier against "government medicine" and a benefit specially designed for the employed middle class of America. In describing the passage of the legislation establishing Medicare (and the accompanying rhetoric), Rothman captures well the ways in which the elderly were presumed to be legitimate objects of governmental protection and how the acceptability of Social Security figured in the rationale for passage in 1965. In accounting for the demise of the Clinton health care reform bill, Rothman covers the ground others have plowed, but he does so with a craftsman's eye for the compelling detail, the vivid illustration, and the example that supports the message of his tale. The same is true for the explication of each of the technological innovations -- who invented them, how they were "sold" as crucial improvements, and how each of them figured in the long-standing dispute over who was to be insured for what in American medical care.

The problem this work presents, then, is one of interpretation, not readability. Taken as a collection of fascinating tales, this is a book well worth reading by any student of American medicine. Taken as an explanation of why American medical care has taken the form it has in the 20th century, this book stretches beyond its intellectual grasp. There are two central reasons for this crucial limitation. First, to narrate an episode -- however compellingly -- is not to explain a later development. Calling such narratives "lived history" does not change matters at all. What such episodes can legitimately do is suggest causal factors that might well, on separate examination of the evidence, support a causal account of the subsequent development. Part of the problem here is linguistic and stylistic. To describe the history of American medical care as an "evolution" is to suggest a dependence of one period on previous ones that is not demonstrated by the simple use of the term.

Let me illustrate such a gap between claim and evidence. Rothman's description of the growth of Blue Cross from the 1930s on is, as noted, an excellent story. But he goes on to claim that it was the "decisive moment" in the "allocation of responsibility" between government and nongovernmental health insurers. Because Rothman believes that his is an explanation of American exceptionalism (the absence of universal health insurance), comparative evidence is crucial here. Canada, for example, also rejected government health insurance in the middle of the Great Depression and expanded the functional equivalent of both Blue Cross and Blue Shield in the decade after World War II. Medically similar, with a distribution of values that made North America not identical, but very close, Canada ended up with national health insurance by 1971 and the United States did not. Each country expanded the role of government in increments. Canada did so according to the type of service (insurance for hospital care in the late 1950s, for physicians' services in the late 1960s); the United States did so according to population groups (veterans in the late 1940s, the poor elderly in 1960, all the elderly under Medicare and many of the poor under Medicaid). It is intellectually questionable, to say the least, to use a common factor (Blue Cross coverage) in the explanation of later developments that differ between Canada and the United States.

It would be churlish to list the many examples of the gap between description and explanation in this otherwise admirable book. The point, rather, is that a collection of essays about moments in history cannot substitute for an explanation of major features of a nation's medical care. One can explain particular episodes well, as Rothman generally does, and still not arrive at a compelling account of why the United States, unlike its counterparts among the industrial democracies, does not have universal health insurance. To do so requires both comparative political analysis and a posing of competing hypotheses against which the evidence is arrayed. Good stories cannot substitute for that.

Reviewed by Theodore R. Marmor, Ph.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

Review

"Rothman's book is an engaging, interesting, and complex one, easy to read, more difficult to evaluate....The episodes are enourmously interesting on their own...Rothman covers the ground other have plowed, but he does so with a craftsman's eye for the compelling detail, the vivid illustration, and the example that supports the message of his tale....Taken as a collection of fascinating tales, this is a book well worth reading by any student of American medicine."--Theodore R. Marmor, Ph.D, The New England Journal of Medicine

"Carefully argued and illuminating..."--The New York Review

"Rothman's argument is nuanced and historically informed; his writing is clear and straightforward: and his conclusion...is thought-provoking and unsettling."--Annals of Internal Medicine

"The major strength of this book is the currency, clinical relevance, and clarity and readability of the text..."--Doody's Journal

"There is much to be learned from this book, both in the history of American health care and in Rothman's often trenchant political analysis. In an environment in which policymakers' institutional memory can apparently be measure in months, not years, there is always benefit to being reminded of how we came to arrive at our current circumstances....One can thus take great pleasure-and learn a lot-from Beginnings Count..."--Health Affairs

See all Editorial Reviews

Product Details

• Hardcover: 189 pages
• Publisher: Oxford University Press, USA; 1 edition (January 15, 1997)
• Language: English
• ISBN-10: 0195111184
• ISBN-13: 978-0195111187
• Product Dimensions: 8.5 x 5.8 x 0.8 inches
• Shipping Weight: 1 pounds (View shipping rates and policies)
• Average Customer Review: 4.0 out of 5 stars  See all reviews (1 customer review)
• Amazon Best Sellers Rank: #1,222,890 in Books (See Top 100 in Books)

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5 of 6 people found the following review helpful:

4.0 out of 5 stars A challenging and thought-provoking essay on health care, December 14, 1999

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Bruce_in_LA "reader_in_LA" (los angeles, ca United States) - See all my reviews
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This review is from: Beginnings Count: the Technological Imperative in American Health Care (Hardcover)

I was surprised to be the first to offer a user review of this book; it was really fascinating. Rothman provides a short, "page-turner", essay-style book looking at landmark decision points in the development of modern U.S. healthcare, from the invention of the iron lung and renal dialysis (rationing problems), to the political battles between socioeconomic classes, AMA, and unions in the development of Medicare and Blue Cross. As I write this, Amazon features a long review from the New England Journal of Medicine which is favorable about this readable and challenging book, but notes the reader may debate Rothman's conclusions as well as agree with them. It's a great overview of modern US healthcare which may leave the reader with more memorable "take home lessons" than the 500-page histories of healthcare and society. Rothman's approach may shape the way you think about other aspects of American culture and history as well !