David's space

[Email letter to Pavel Komyukhov, a young Russian composer and computer technician living near Moscow]

Dear Pasha,

Thank you for your reply and your fine MIDI file of your 1999 composition. I have just played it on my PC and I find it most impressive. It is certainly very tonal and resolves immediately to D minor. However, it stays in that key throughout the duration of the piece, resolving over and over to D minor without even trying to modulate to any other key. This creates a very static effect and makes it too predictable -- there are no surprises. If I were writing such a piece, I would create more tension by having ambiguity about the direction, modulating unexpectedly to other keys, and delaying the resolution as long as possible before returning to a final resolution, and then only once near the ending of the piece. I'm sure your more recent work has undergone considerable changes, so I do not know if this criticism is still a propos.

Although I am 71 years old, I am not able to retire because my Social Security pension is not sufficient to pay all my living expenses, so I had to take a job. In the town where I live, jobs are very hard to find, so I had to take the only one that was available here. I am the general cashier for the two biggest resort hotels in my town, which are next to each other and owned by the same family. I am responsible for handling all the cash that is received from the hotel reservations, restaurants and bars, and I have to process the daily deposits, enter the amounts in the computer and take the deposits to the bank each day. I also have to keep all the departments supplied with enough money to make change for the customers. Because of the nature of my job, I have to work six days a week, with only Sundays off, so I have very little free time to work on my music or on my email. I do not consider this job as my career, and I still cling to the dream that I am really a composer and that is my actual life's work.

I do not like to make definitions of artforms. Many years ago, I took a course in Russian literature with your illustrious countryman, Vladimir Nabokov, who was then on the faculty of my school. Professor Nabokov always used to tell us that literature is a "divine deception." In other words, it is a form of illusion designed to fool us into believing a scenario that does not actually exist. I would take this concept one step further and apply it to all the arts. In painting, it is simply pigment on a canvas designed to fool the eye into entering a particular reality, and in poetry it is an artform that makes use of words as a form of nonverbal expression. In music, it uses the features of sound (tone, timbre, volume, rhythm, duration, etc.) to create a dramatic illusion that causes an emotional reaction (and also a kinetic reaction, in connection with the rhythms). However, I have to stop short of trying to define any of the arts in terms of words alone, because every one of the arts does what words alone cannot do, and that is the whole point of art. Words are very inadequate as a means of expression, and any attempt to describe an artform in verbal terms is sure to end in failure. The arts are needed to do what words alone cannot do.

As a child, I was very musically gifted. I came from a musical family, and both my parents studied at Juilliard School of Music in New York. My mother was a pianist and my father was a singer. I first started playing the piano when I was three years old, but I did not take my first piano lesson until I was seven. When I was ten years old, my family lived in New York City and my mother enrolled me in the Juilliard School children's classes, where I studied piano with Maro Adjemian (an Armenian/American concert pianist who gave the first performance of the Khatchaturian Piano Concerto in the United States, and later became famous for recording all of the music for "prepared piano" by the American avant garde composer John Cage). I also studied theory and musical composition there with Suzanne Bloch (the daughter of Ernst Bloch). However, when I was eleven my father was transferred out of New York City to another job 300 miles away, so my family had to move and I was unable to continue my studies at Juilliard. A few years later, I entered Cornell University and majored in Art History because my father did not trust my ability to support myself financially on the basis of my music (even though he had a musical background, he himself had a very negative impression of music as a career, often referring to a composer-friend who spent the years of the Great Depression [1930s] starving in an attic, writing quartertone music that never got played or published). Since I had also shown some interest and talent in art, my parents encouraged me to become an industrial designer because they thought it would be a better profession for me to make a living. I still managed to take as many music courses at Cornell as I could, and while there I studied composition with Karel Husa a young Czech composer and conductor newly arrived from Paris who had studied with Artur Honigger, Olivier Messiaen and Nadia Boulanger. After I completed my undergraduate degree at Cornell I studied industrial design for one year at the Institute of Design in Chicago, but had a disagreement with the school director and left after the first year. My father encouraged me to accept a position in social work (which did not make use of any of my talents), but I continued to dabble in music occasionally for several years until I moved to San Francisco in 1963 and, after working there for a few more years, saved up enough money to attend San Francisco State University, where I eventually got my masters degree in musical composition in 1974. I am, unfortunately very shy and I was afraid of getting into a college teaching program where I would have to deal with administration officials and faculty members. For the same reason, I was afraid to become a conductor because I was frightened about working with other musicians and appearing before audiences. When the computer revolution occurred, I jumped at the chance to acquire a home music studio and write my music on the computer. I took a course in MIDI and assembled a studio from the best components I could find in the 1990s. I was able to transcribe and edit my older compositions into MIDI files and write new ones directly onto the computer. So far I have managed to create a number of works, including three string quartets, a woodwind quintet, a tone poem for soprano chorus and orchestra, a symphonic scherzo, a fantasy for winds, and two symphonies, as well as a number of shorter works.

I managed to download a MIDI file of my 1999 New Century Fantasy for winds into my computer, and I am attempting to send it to you in this email. It is set up to play on Windows Media Player. This is the first time I have ever attempted to send music files over the Internet. Let me know if the transmission was successful, and if so, I'd like to hear your opinion of the piece.

I used Finale 3.2 for most of my music, including the piece I sent you, but I now have Finale 2005, which I still have not gotten around to using for composition because I have been too busy with my other activities. The new Finale versions are totally different from the one that I used originally and, since I did not grow up with computers, I find it difficult to adjust to changes in this technology. My main reason for switching to the newer version was that I bought a new Apple computer with a 20" monitor in order to be able to view two full pages of score at once, because using my old computer with its 15" monitor and half-page viewing area was like peering through a mailslot when I tried to edit my scores. I wanted to be able to view the entire score at once. In order to use the new computer, I had to buy new software because the older version of Finale is not compatible with the operating system of the new Apple computers.

Although piano, as well as other keyboard instruments, is my major instrument, I am not a very good pianist and have no desire to play in public. My technique is just good enough for me to use for my own compositional purposes.

Here it is folks -- the real reason that America does not have national health insurance:

Most of you are too young to recall the disastrous chain of events that led to our current heathcare dilema. If you read this, you will understand why America now has the dubious distinction of having the world's best available medical care, coupled with the world's worst healthcare delivery program.

United States health reform under Truman [From Wikipedia, the free encyclopedia]

Introduction

Health reform under President Harry S. Truman (1945-1953) was inspired by former President Franklin D. Roosevelt. Truman supported a national health insurance program and made his stance clear during his presidency; in 1945, he addressed the nation and recommended an establishment of universal health insurance program, federal funding to propel medical education and the construction of hospitals, as well as increased monetary aid for maternal and child health services. Truman's adament support for health care reform, established early in his presidential term, continued to be expressed throughout his time in office. In his 1947 State of the Union, Truman stated "[o]f all our national resources, none is of more basic value than the health of our people." In his 1948 address, he said "[t]he greatest gap in our social security structure is the lack of adequate provision for the Nation's health.". Unfortunately, Congress did not mutually share the lofty aspirations of the President (Mayes 2004: 36). Congress's lack of action coupled with the presence and disapproval of the American Medical Association to universal health insurance resulted in limiting the progress of health policy reform during the Truman era (Mayes 2004: 37).

The issue

Background

Universal health insurance, which was left out of Social Security, was not completely supported by the President until the 1940s (Starr 280). However, with the Cold War, the idea of "socialized medicine" seemed like a symbol of the "communist influence in America" (Starr 280). While Congressional bills such as the Wagner-Murrary-Dingell bill, proposed in 1943, set out to create a "cradle to grave" social insurance system (Starr 280,) it was not until 1944 that the President (President Roosevelt) finally asked Congress to develop a plan to give every American citizen health care (Starr 280). After the death of Roosevelt and the end of World War II, Truman again called on Congress to pass a national program which would expand "investment in the medical system" (Starr 280). Thus began Truman's attempt to revitalize the health care system.

Truman's attempts to adopt a form of a single-payer system were met with opposition, both from the public and from special interest groups. Although polls confirmed that over 58% of Americans approved of Truman's propsal, his programs seemed too liberal and radical for the American public(Greenberg 20). Because of external forces like the "Red Scare" and the commencement of the Cold War, Truman's health reform plan never had a chance (Hamby 659). Domestic policy like health care reform was not the priority at the time. Moreover, the American Medical Association (AMA) vehemently attacked Truman's ideals.

The American Medical Association was a very powerful force and dominated "interest-group activity in the health policy arena" (Mayes 37). With endless funds, the AMA attacked Truman's proposals as Communistic and ultimately destroyed any chance of success for Truman. The AMA felt that any creation of a health care plan under Social Security would be a stepping-stone for the government to take over the entire health care system. In their opinion, this would result in inefficiency and an overall decrease in the quality of health care in the United States (Mayes 37).

How the issue got noticed

There were rumblings of universal health coverage plans in California, beginning with the election of Culbert Olson in 1938 as governor (Mitchell 11). Olson's platform contained a focus on state health insurance, but his inabilities as a leader served as its doom (Mitchell 11). When Earl Warren won the governor's seat in 1943, he too put a premium on enacting state-wide health insurance. Warren entered the office in a positive place: with a swollen state tax revenue and support from both Democrats and Republicans for his programs (Mitchell 13). Thus, Warren began initiating his own health proposal in 1943, for presentation in 1945. Warren made himself a national figure in 1944 by turning down Dewey's invitation to run for vice-president, and thus his proposals were well-recognized (Mitchell 16). Warren's hard push for universal coverage in California likely stirred the interest of Truman, and had Warren been successful, Truman may have favored more of a state run health system (Mitchell 30). Additionally, California was seen as an innovator, and high-profile state which many states would likely have followed had they been successful in enacting state-wide health coverage (Mitchell 3).

On November 19, 1945, Truman became the first president to fully support national health insurance. His support for this reform "evolved from his dismay that one-third of the men reporting for the draft during World War II were physically unfit to serve. Whats more, Truman's populist foundation was shaken by the economic inequalities of medical care" (Greenberg 20). Over thirty-nine percent of registrants for the armed services were rejected due to poor health; poorer states ran much higher than this average. Over fifty-six percent were rejected in North Carolina and fifty-five percent were rejected in Arkansas (Frothingham 1947: 52). With the lack of funds for health care came a lack of qualified physicians. Studies at the time showed that in New York City there was one physician for every five hundred inhabitants, but in the United States as a whole there was one physician to every seventeen hundred (Frothingham 1947: 52). Truman, himself, exhibited an extremely personal and passionate desire to enact a national health care plan.

How the issue was framed

Truman's health reform was similar to that of FDR in 1938, but Truman's emphasis was different. First he wanted an expansion of hospitals and then increased support for public health services. He also wanted federal aid to medical research and education, a difference between his plan and FDR's plan. It was a single health insurance system to include all groups of people. In essence, "the Truman program was expansionary in several senses: It aimed to expand access to medical care by augmenting the nation's medical resources and reducing financial barriers to their use, and it promised doctors higher incomes and no organizational reform (Starr 281). In it's simpliest breakdown, the Truman plan had five major proposals: (1) Federal grants-in-aid for hospitals and other health facilities throughout the Nation; (2) Federal grants-in-aid to expand public health services and maternal and child health services; (3) Federal grants for medical education and medical research; (4) A Nation-wide system of health insurance; and (5) Compensation for wage loss due to non-industrial disability (Altemeyer 1945).

Opposition to Truman's healthcare reform framed this negatively. They felt that increased government control on American health care would result in socialized medicine. They therefore portrayed Truman's reform as an increase in big government, which would result in lowered competition. This leads to increased medical fees, inefficiency, and a result of "damaging the high quality of American health care" (Mayes 37). Their efforts of framing Truman's reform negatively largely resulted in the failure of Truman to be able to make any progress.

The greatest opposition, the American Medical Association, framed and labeled national health insurance as "socialized medicine" (Starr 285). This framing took advantage of the global sentiments of the United States. The fear of communism rose greatly starting at the end of the 1940's. This resulted in a twenty-two percent decrease in public support in 1949 (Starr 285).

The framing of health reform by opposition effectively targeted the vulnerability of America to the expansion of big government and the increasing fear of the spread of communism.

The policy stream

Policy communities

The political community during the Truman presidency was influenced and fueled by interest-group politics. Policy was influenced largely by the American Medical Association. Their opposition and negative support for universal health insurance coupled with their financial firepower resulted in a crippled health policy community, whose ambitions were to expand policy for universal coverage (Mayes 37). For example, in the 1950 Congressional elections, Florida physicians banded together to defeat Senator Peppers, whose Congressional committee pronounced in 1943 that national health insurance was the only sure way to meet the nation's health needs. Physicians ran half-page ads in local newspapers showing Senator Peppers posing with Paul Robeson, an African-American singer and a member of the Communist party (Quadagno 2005: 42). In Pennsylvania, physicians sent 200,000 letters and posted notices in waiting rooms asking patients to vote for Republican candidates in order to defeat the Democrats who supported national health insurance (Quadagno 2005: 41).

The strength of physician interest groups, and their opposition to proposed forms of universal health insurance was evident during the Warren administration in California in 1943. Warren felt that he had a good relationship with the California Medical Association (CMA) (Mitchell 17), but because he proposed the plan before the CMA had time to meet and discuss it, they immediately rose up against Warren (Mitchell 18). The CMA then hired the powerful political consulting firm, Whitaker and Baxter, to campaign against Warren (Mitchell 18). This shows that the physicians interests were in fact quite powerful and would use any means necessary to oppose plans that could "socialize" medicine.

Policy entrepreneurs

Arthur J. Altmeyer was Truman's Chairman of the Social Security Board. As a part of the President's Committee, he took part in drafting the preliminary legislation for Social Security (Dewitt). His involvement in the Social Security Board gave him great power to try to advance healthcare reform. He spear-headed the efforts to promote Truman's health policy. In explaining Truman's new plan, he said that "doctors and hospitals would be permitted to choose 'the method of remuneration they desire' and that doctors had the right to expect high average earnings than they had received before" (Starr 281). Altmeyer held the view that healthcare was an issue of wefare and equality. He hoped that the future of the nation's healthcare would result in providing universal coverage for all, and not just a certain group of persons (Dewitt). Although he held this opinion on the direction of healthcare, he was very mindful of the national mood, and tried to frame Truman's reform differently. Altmeyer was trying to explain that Truman's plan was not "socialized medicine," because at the time, the red scare and a fear of communism was hurting Truman.

Michael M. Davis was the Executive Chair of the Committee for the Nation's Health. The Committee for the Nation's Health initially lobbied in support of Truman's national health insurance place. Another role of the Committee for the Nation's Health was to promote and organize groups to join in the campaign for national health insurance.

Oscar Ewing, a graduate of Harvard Law School where he was elected to the Harvard Law Review, was appointed to the head of the Federal Security Agency. Truman told Ewing to assemble "all the resources within the Federal Security Agency for vigorous and united action toward achieving public understanding of the need for a national health program" (Quadagno 2005: 30). In his The Nation's Health: A Report to the President, Ewing called for a national health insurance program to right the inequities in health care so prevalent in the US, mainly in the South where racial discrimination pervaded the system (Quadagno 2005: 30).

The origin of the idea of National Health Insurance

The idea of National Health Insurance was considered after the enactment of the New Deal. Although excluded from the initial legislation, the idea of publicly funded medical care seemed an eventual addition. These forms of government-run were observed in other countries and being proposed in Great Britain (Starr 280).

The political stream

The national mood

The sentiment of the nation was influenced by the conflicts of the United States on the international level. The start of the Cold War resulted in the growing fear of the spread of communism. Therefore, an expansion of government to create universal healthcare coverage created national concern. Public opinion felt that nationalizing medicine would open opportunities for socialized government in other realms of public life (Starr 280).

The close of World War II and the emergence of the Cold War brought about a heightened fear of communism. On March 11, 1945, federal agents raided the offices of a left-wing scholarly journal, Amerasia, and found thousands of State Department classified materials (Quadagno 2005: 28). The ensuing federal investigation found that federal employees had been giving secret documents to the Communist Party. Truman formed a loyalty board to inspect federal employee ties to communism. Increasing the public fear was the renewed activities of the House Un-American Activities Committee, or HUAC, which began a highly public investigation of communist penetration of Hollywood. Even though the search produced very little in the way of uncovering any suspicious activity, the fears of the public were nonetheless fueled. HUAC also managed to convince the nation that they had found a communist spy in Alger Hiss, high-ranking State Department official, though he was only found guilty of perjury. A young Republican by the name of Richard Nixon was thus credited with nabbing the biggest spy in State Department history (Quadagno 2005: 29).

Organized political interests

Physicians In the 1940s, the American Medical Association (AMA) was the most powerful interest group involved in health care policy issues. The AMA immediately denounced Truman's proposal. Doctors argued that government interference "risked damaging the high quality of American Health care"(Mayes 37). The organization presented a program of its own in 1946 that focused on "voluntary alternatives to compulsory health insurance." (Maioni 19) In one of the largest campaigns concerning the issue of health care, the AMA spent a total of $5 million denouncing Truman's plan. Using Cold War terminology, they came up with the phrase "Socialized medicine" when describing universal health care (Mayes 38). The AMA utilized Cold War era anti-communist sentiment to help rally support. In 1947, a House sub-committee reached "a firm conclusion that American communism holds this program as a cardinal point in its objectives and that known Communists and fellow travelers within federal agencies are at work diligently with federal funds in futherance of the Moscow Party line" (Greenberg 20). In reality, Lenin and the Russian communists were not promoting the same ideas as Truman. Furthermore, Truman was not advocating making doctors and hospitals part of the federal bureaucracy - he simply wanted people to have the opportunity to choose their own health care. However, the AMA continued their crusade. The AMA also said that the administration and Congress failed to specify how doctors would be paid and how states would be involved (Mayes 38). Support of Truman's plan in the public polls due to anticommunist sentiment and the success of the AMA's campaign decreased from 58% to 36% in 1949 (Mayes 38). Therefore, historians have suggested that "the AMA's victory secured health insurance exclusion from any public path" (Mayes 39). There were other organizations such as the American Hospital Assoication, the American Bar Association, the Chamber of Commerce, the National GRange and the Children's Bureau who favored privatized medicine. "Even the agencies of the federal government did not all wholeheartedly backe the president's plan. The Children's Bureau was more interested in expanding an insurance program for wives and dependents of servicemen that had been started during the war. The bureau was wary of jeopardizing the future of this program by associating it with the more controversial national health bill" (Starr 283).

Labor. The labor movement initially lined up behind Truman in support of his plan for a federally-run health insurance system (Derickson 1341). This is not surprising given labor's strong endorsement of the initial Wagner-Murray-Dingell bill (Derickson 1340). Labor's approach changed after the 1946 elections led to Republican majorities in both houses (Derickson 1344). Without significant movement on Truman's health insurance plan, labor increasingly began to pursue an alternative strategy of negotiating with employers for the private provision of health insurance (Derickson 1344). Collective bargaining efforts fragmented labor's support for national health insurance. For instance, the United Mine Workers was one of the first unions to aggressively pursue collective bargaining. Once it succeeded in obtaining benefits for a significant portion of its members, national health insurance was no longer of interest to the union (Derickson 1345-46). Other unions did not explicitly reject national health insurance, as UMW had, but their pursuit of private solutions through collective bargaining undercut the movement nonetheless (Derickson 1352, 1355). The growth of private health insurance benefits during this period is striking: Gordon (297) indicates that hospital insurance and surgical insurance covered less than 6 million and 1.4 million individuals respectively in 1939. Those numbers rose to 24 million and 8 million in 1945 and to 60 million and 39 million in 1950.

Government

On September 6, 1945, five months after having become President after a short four month tenure as Vice President, Truman outlined his "Fair Deal" initiative to Congress. This plan, among other features such as raising the minimum wage and building public housing, focused on improving health care (Quadagno 2005: 27). Truman said that he had "been troubled by seeing so many sick people unable to get the care they need, turned away from hospitals because they had no money" (Quadagno 2005: 27). Bills were introduced in the Senate and the House, but no action was taken that year. In 1946, the bipartisan Hill-Burton Act was passed, which allocated federal funding for hospital construction to states.

Competition within the government was fierce. In Congress, many Southern democrats who opposed Truman's pro-union and anti-segregationist mentalities, sided with the Republicans, defeating many of Truman's proposals (Greenberg 20).

Senator Taft had crafted an alternate bill to that of Truman which was gaining support with the AMA, various physicians' groups, the United States Chamber of Commerce, the National Grange and representatives of the American Farm Bureau. Taft's proposal recognized a need for federal assistance in health coverage, but only authorized federal money to states that provided care for the indigent (Morgan 130).

The policy window for health reform

Why the window of opportunity for health reform opened

problems related Some of Truman's ideas for health reform came on the heel's of FDR's New Deal. Post World War II, Truman showed much support for health care reform. This could have been due to presence of domestic health to the war efforts. After resolve of foreign conflicts, the country and President Truman saw necessity of stabilization of health care in America.

President Truman was one of first presidents to support a healthcare insurance program throughout his term. In fact, on November 19, 1945, he was the very first president to deliver a presidential message which pertained solely to healthcare (Mayes 36). He therefore brought this issue to the public eye and framed it as a large public concern, therefore creating demand and opportunity for healthcare to be reformed.

Why the window of opportunity for health reform closed

Two things were necessary for the success of Truman's health program: unity of purpose among the promoters amd a strong executive leadership - neither of which Truman had. Ultimately, "White House support stalled, and New Dealers became increasingly disenchated with Truman. The loss of a Democratic majority in the 80th Congress made national health insurance a moot question" (Morgan 130). Republicans attacked Truman's plan as communist-inspired and assailed big government and the New Deal/Fair Deal. Thirty-nine of the sixty-nine most liberal Democrats, supposedly the most likely to support Truman, lost their seats; Republicans hailed this as a clear mandate from the people to throw out the "communists" and their ideals (Quadagno 2005: 27).

Truman's personality was also a hindrance to the passage of national health coverage. He was excessively optimistic as well as extremely stubborn. Truman himself defined a leader as "a man who has the ability to get other people to do what they don't want to do, and like it" (Chalberg 262). This mentality ended up hurting Truman's efforts.

Although Truman's health policies did not pass, that is not to imply that no gains were made during his presidency. In fact, "the 1950 social security amendments which helped the states provide medical care for the elderly, the blind, dependent children and the disabled were a significant achievement" (Morgan 130).

Also, during Truman's presidency, the nation faced much domestic prosperity. For example, manufacturing wages increased thirty-one percent during the time of Truman's term (Starr 313). Therefore, the majority of people did not experience the financial hard-times, such as during the Roosevelt Era. Therefore, the public did not see much of an urgency to reform public systems during a time of prosperity.

In addition, there was a major resource gap between the reformers and the opposition. For example, the Committee for the Nation's Health spent about $36,000 in 1950. Whereas the AMA spent over $2.25 million in the same year on its "national educational campaign." (Starr 287). AMA also had strong business sector support. Overall, Starr explains that "between the two sides in the conflict, there was a gross imbalance in resources, partly material, partly social, partly symbolic. And these imbalances reinforced one another: The edge that the opposition enjoyed in its social bases of support could be translated into material advantages and means of influence" (Starr 287).

Ultimately, in the failure of Truman's health plan, those who were not well off became worse off and those who were well organized became better off. Instead of Truman's plan, "American society provided insurance against medical expenses primarily to the well off and well organized. The people who lost out were those without membership in groups, like veterans and unions, that had political influence or economic power. The poor, for whom health insurance was originally conceived, were precisely the ones who did not receive its protection" (Starr 289).

References

Altmeyer, Arthur J. "How Can We Assure Adequate Health Service for all the People?" Speech at the First Annual Conference of Presidents and Other Officers of State Medical Societies, Chicago, Ill. December 2, 1945.

Chalberg, John C. "Keeping Cool with Harry," Reviews in American History, 13.2 (1985), 262-268.

Derickson, Alan. "Health Security for All? Social Unionism and Universal Health Insurance, 1935-1958." The Journal of American History 80(4) (1994), 1333-1356.

Dewitt, Larry. "Social Security Pioneers." Social Security Online. 07 Nov. 2005 <http://www.ssa.gov/history/bioaja.html>.

Frothingham, Channing. "The Health of the Nation: A Plea for Public Medicine." The Atlantic Monthly, Vol. 179, No. 2, pp. 52-54.

Gordon, Colin. "Why No National Health Insurance in the U.S.? The Limits of Social Provision in War and Peace, 1941-1948." Journal of Policy History, vol 9(3) (1997), 277-310.

Greenberg, Jonathan. "Give ‘em Health, Harry: Harry S Truman’s Failed Health Reforms)." The New Republic, vol 209 (1993), 20-21.

Hamby, Alonzo L. "The Vital Center, the Fair Deal, and the Quest for a Liberal Political Economy." The American Historical Review, vol 77 (1972), 653-678.

Maioni, Antonia. Nothing Succeeds Like the Right Kind of Failure: Postwar National Health Insurance Initiatives in Canada and the United States. Journal of Health Politics, Policy and Law, vol 29, no 1 (1995).

Mayes, Rick. Universal Coverage: The Elusive Quest for National Health Insurance. Ann Arbor: The University of Michigan Press, 2004.

Mitchell, Daniel. "Impeding Earl Warren: California's Health Insurance Plan that Wasn't and What Might Have Been." Journal of Health Politics, Policy and Law, vol 27, No. 6 (December 2002): 947-976

Morgan, Anne Hodges. "Is There A Doctor In the House? ... Or For the House?" Reviews in AMerican History, 8.1 (190), 129-133.

Quadagno, Jill. "One Nation, Uninsured." Oxford University Press, 2005.

Starr, Paul. The Social Transformation of American Medicine. New York: Basic Books, 1984. ISBN 0-465-07935-0 (paper).

Truman's State of the Union Message: 1947, 1948

Retrieved from "http://en.wikipedia.org/wiki/United_States_health_reform_under_Truman"

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[Response to the above mailing received from a close physician-friend]

Dear Dave:

It was very interesting to read this summary of the politics of Natl. Hlth. Insur. going back to the 30s, only part of which I was aware. Right now, Kaiser has purchased a local HMO Clinic, of which I was a member to 1974, years before they became an HMO. About 40,000 lives are insured with this Clinic, and I expect Kaiser to hold on to those people's allegiance, for cost reasons alone. The quality of the outpatient care there is at least two rungs below the care in the private community (except for a few general paractitioners whose patient populace is also mostly HMO). The HMO doctors give short shrift in time allotment for their patient visits, short shrift for medicines they choose--meaning the oldest ones on the market with significantly higher side effect incidence than the newer replacements, to save the HMO money in their pharmaceutical formulary, and short shrift when patients are ill and need specialist referral(no referral granted; just read the paperback handbook on how to treat such and such and Dr. G.P. does a replica of the cookbook, not allowing for the complexity of a disease state and its interaction with other coexisting diseases the patient might have.

Once Kaiser is here, in a few months, they will press the hospital, already strapped due to Medicare and Blue Cross payment cutbacks, and in the red, to lower room rates to practically "break-even", alternative being Kaiser will take all the Ventura patients to Oxnard. This, in the midst of a large fund raising campaign by our local 200 bed hospital, to provide rebuilding and expansion. This project is especially needed due to earthquake requirements that have to be in place by 2010. If the hospital refuses the speculated Kaiser offer and the patients are taken to Oxnard for all but absolute emergencies by ambulance, the local specialists will have to move their practises elsewhere to have enough inpatient volume to keep up their skills, and have their practises survive, economically.

The message I am espousing here is that the HMOs and the "private insurers" like Blue Cross who illegally announce fee schedules to doctors and hospitals without negotiating , will achieve cost cutting, as far as what bills they get in the mail. The result will be similar to what would happen under National Health Insurance. Large profits will go, as they have so far, into the hands of the executives of the HMOs and private insurers. However, choices made on what is allowed for patients to utilize (specialists where needed, medications where needed, extra hospital days where needed) will be bad under the currently developing system as listed above. I fear they would be the same under an all-encompassing government program.

Examples: Fed. Govt. limits medicaid to Tennessee and Kentucky, unanticipated needs appeared among the patients of those two states a few years ago, and the money ran out, payments for both doctors and hospitals were suspended, and county-run charity clinics and county hospitals had to provide the additional free care, with big threats to county budgets and other county services.

Medicare comes out with Plan D medication insurance. The limited choice of medications covered as "first tier" is a joke among doctors and pharmacists. To save money, they put budgetary costs way before patient needs, comfort, and safety. Part of this is in the newspapers under the guise of "patient confusion". No confusion would have resulted if all the private carriers had just been given the regulation by the government that all medications be covered, and funding increased accordingly. I guess the crisis could be relabeled "doctor confusion", as I spend hours a week talking to patients about what their choices are under plan D, and then trying to win the approval of the pharmacy insurance companies for alternate drugs not covered on D , writing letter on behalf of the patients, having my staff occupy their time calling pharmacies to coordinate my appeals--to the point where it interferes with the hours available for me and my staff to provide the basic care needed for my many patients.

Doctors don't all want to be rich. Yes, the AMA was wrong to use scare tactics about communism and socialism to fight a national care plan. But they were right, in my opinion, about the socialism aspect as it relates to "lowest common denominator" or "cheapest common denominator"---provide what helps the majority of the populace without risk to them so save a buck of taxpayers' money, but the hell with the occasional patient who will be excessively tired on the cheapest medicine and can't afford paying more for the better, newer medicine of the same class, and it's not covered on plan D. Most doctors object to the fact that any beaurocracy in charge of health budgeting, Blue Cross, HMO, or the Feds, will "dumb down" what is provided for the medical care, in order to save a buck. Doctors are now already dealing with this on a daily basis. Even those who put in the time to appeal these arbitrary decisions affecting many of their patients, often find their efforts are totally thwarted by a big "NO to your written appeal."

When I get denied hundreds of dollars a month by Medicare and Medical for "repeating an echocardiogram too often" with further insults when the govt. sends a duplicate of the denial to my patients with the statement "considered medically unnecessary", in the patient whom has rapidly progressive heart disease needing more frequent testing l.... all because some idiot in the govt. hired some idiot cardiologist who probably hasn't practised medicine for over 10 years and does administrative work only, and set a standard of "no echocardiogram shall be reimbursed if done more often that once a year"....

my problem is the aggravation and time explaining this all to the patient to undo the poison pen letter of the govt., the rascals who intimate that my care is sloppy and I order tests too often; not so much the loss of revenue and the resources expended to do the echocardiogram. I am precluded by law from collecting what Medicare and Medicaid do not allow, from the patient. Medicare is payor and sole judge of whether my tests are reasonably provided. The "appeal process" is done by administrator judges hired by Medicare, and my loss rate for appeals has been 90% in the past 5 years, so I gave up appealing recently. The time spent cut into my patient care too much!

These abuses of power, I am afraid, are bound to happen when the payor covers the majority of the populace in any area of the country, as shown for Medicaid patients, Medicare patients, and HMO payers. There is no easy answer. Maybe, pessimistically restated, there is no answer.

There is going to be a big doctor shortage in the next 5-10 years. The worst in the history of our country. For comfort and longevity reasons, the populace all want the best specialists and best medicine available. Because of the well known hassle of the beaurocracy noted above, because of the cutbacks on reimbursal from the organizations, private and governmental, cited above, because of the high overhead to run a medical office with inflation, genl. insurance, and malpractise insurance, the application rate for medical schools and residencies is already way down. The local family practise residency now accepts the majority of the applicants (many poorly trained as D.O.s), whereas, it took less than 1/4 who applied, 10 years ago. Internal Medicine, Anaesthesiology, and Radiology, Orthopedics, and Cardiology are among the hardest hit. There are empty spots, unfilled, in good residencies of the above noted specialties. The quality of applicants accepted is way down, on average. The right wingers in the AMA may well say, "the population got what it deserved". I can restate that, that if this scenario really develops, " the populace supported their representatives in their (populace 's and representatives') ignorance, and the intertia of government created a nightmare of bad quality care".

"Gravy extenders", otherwise known as nurse practitioners, are not the answer. Locally, many doctors tried it and found the quality of care and patient satisfaction both dropped substantially, and they dispensed with keeping nurse practitioners in their practises. Those who kept them turn out nightmare scenarios, often, that I get to see when the patients show up at my office or in the emergency room as "railroad wrecks", and I try to pick up the sticks.

Student loans by govt. to support high medical school tuitions (total costs $150--200K for four years) aren't the answer. The debt service only adds to the anxiety of those who might apply, and dissuades them when they consider what it costs to start a practise, rent space, pay insurance, buy equipment, and get further loans for same.

Through all this morass, I must say that the average quality of teaching in the medical schools has gradually declined for 20 years, in my direct experience teaching residents. Many residencies are still of high quality. Paradoxically , the latter exists because the relative attractiveness of town vs. gown shifted toward gown for many. For these individuals, better to receive 20% less income and not deal with the risks and headaches of a private medical practise. The counter force is dealing with the personalities and beaurocracy one is trapped in with the medical school and residency teaching jobs. It only takes one sociopathic or dishonest superior, in that setting, to ru