The high point of efforts to improve access to health care by "documentation." - Committee on the Costs of Medical Care - National Health Policy

Physician Executive, Nov-Dec, 1992 by Norbert Golfield

The set of articles of which this article is a part has documented the tension between the advocates and the opponents of government intervention in the American health care system. This article will focus on a chapter of American health care history that is almost forgotten and has still never been told in its entirety. The story of the Committee on the Costs of Medical Care (CCMC), which existed from 1927 to 1933, represents the apogee of the factual approach effort to changing health care delivery in America.

Advocates of significant change in the American health care system have typically focused on documenting problems in access. These advocates have typically used the "factual" approach in an effort to increase government intervention. While recognizing that problems exist, opponents of government intervention strongly believe that government involvement is many times worse than the problem of access. As documented in the first articles in this series, opponents of government intervention rally around the un-American nature of government intervention. The editor of Postgraduate Medicine exemplifies this perspective with an almost monthly railing against the evils of government involvement in the health care sector: "I woke up in the middle of a terrible nightmare the other night. We had full blown national health care, and HCFA inspectors were swarming all over my office....My guess is that most people who think they want a national health insurance program don't realize that what they will get is government. Lots of government (emphasis in text). Something like a combination of the IRS, the postal system, OSHA, Medicare, Medicaid, and CLIA."[1]

The approach of the Committee on the Costs of Medical Care (CCMC) was to document in extraordinary detail the status of health care in the United States. In many respects, that effort, which has never been repeated, still reflects the current state of access to health care services in America. Supporters of CCMC believed that facts alone would convince all interested parties, ranging from the American Medical Association to public health advocates, to not only improve access for the uninsured but to agree on a new direction for the organization of medical care delivery in the United States. This wonderfully naive, some might say silly, perspective was doomed to failure, because CCMC members and research staff ignored the political underpinnings of the facts it documented. In addition, supporters of the final majority report of CCMC never realized that the choice of which facts describing the American health care system to present represented a conscious political decision.

Despite the political fate of CCMC, many of its recommendations have come to fruition. Government intervention has played a minor role in comparison to changing market and social forces that have buffeted American health care over the past quarter century. For example, CCMC's recommendation that growth of group practices be encouraged instead of individual practitioners has been realized. This has happened not because of government incentives but rather because of changing life-styles and economic considerations on the part of physicians. In addition to the ultimate success of many CCMC recommendations, we can learn from the political fallout of the group. These political lessons are telling of the unbridgeable gulf between advocates and opponents of government involvement in health services.

The Historical Setting

When efforts to enact national health insurance (NHI) prior to World War I failed, political activity on a national scale quieted down for several years. However, legislative achievements continued to occur at the federal level, notably the Shepherd-Townes bill. This important law, which expanded access to health services for a vulnerable population, occurred despite a climate that virulently opposed many progressive efforts, labeling them socialist or, worse, Bolshevik. It is hard to describe the political tenor of the twenties. Many readers will be familiar with the happy-go-lucky business atmosphere, but there were darker sides to this era. As the late philosopher Sidney Hook remarked in his autobiography, the anti-German, anti-Bolshevik, and, by association, antiprogressive hysteria was much worse than virtually anything Americans were exposed to during the McCarthy years: "The mildest kind of dissent--a mere word, a grimace, a misinterpreted gesture--was often an occasion for physical violence."[2]

Final CCMC Recommendations: Majority and Minority Reports

The majority and minority recommendations published in CCMC's summary report reveal much regarding the political orientation of CCMC members:

Majority Report:

"I. The committee recommends that medical service, both preventive and therapeutic, should be furnished largely by organized groups of physicians, dentists, nurses, pharmacists, and other associated personnel. Such groups should be organized, preferably around a hospital, for rendering complete home, office, and hospital care.