Reading Ted Kennedy's In Critical Condition: The Crisis in American Health Care.

How to fix health policy.
Sept. 1 2009 7:38 PM

Reading Ted Kennedy

The late Senator's 1972 book proposed a health care solution more radical than today's yet described problems that were less severe.

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Ted Kennedy. Click image to expand.
Ted Kennedy

Since Ted Kennedy's death last week, various commentators have sought to redefine the Senate's pre-eminent liberal as some sort of moderate Howard-Baker-style Republican. Writing in the New York Times, David Brooks dubbed Kennedy "The Great Gradualist," a legislator whose actions came to reflect that the American people reject "proposals that centralize power and substantially reduce individual choice." Appearing on ABC News'This Week, Sen. Orrin Hatch, R.-Utah, said, "[T]he people out there are very concerned. They don't want a Washington-run government plan. It's just that simple. … Teddy would have recognized that." The program's host, George Stephanopoulos, said the same in an appearance on Fox News'The O'Reilly Factor.

Set aside, for a moment, the practical reality that nobody is able at this moment to identify any concession on health reform that would win a single Republican vote. The larger point is that in embracing a public option (i.e., creating a government health insurance program available to a relatively small subset of the uninsured) Kennedy was already compromising on his longstanding belief that Medicare ought to extend coverage to all Americans. "I eventually came to believe that we'd have to give up on the ideal of a government-run, single-payer system if we wanted to get universal care," Kennedy wrote in the July 18 issue of Newsweek. Kennedy seemed to suggest that this revelation struck him in the mid-1970s. But in his 2006 book America Back on Track, Kennedy wrote, "The most effective option is to expand Medicare to cover all Americans." As recently as 2007, Kennedy introduced (with Rep. John Dingell) a "Medicare For All" bill. It is therefore possible that among those guilty of exaggerating greatly Kennedy's willingness to deal away a government health insurance program as the solution to the health care mess was Kennedy himself.

Seeking respite from bipartisan pieties, I turned to Kennedy's long-out-of-print book InCritical Condition: The Crisis in America's Health Care. Published in 1972, it the product of an era when most congressional Republicans stood well to the left of most congressional Democrats today. Kennedy's discussion of the health insurance industry was especially blunt. One chapter subheading read: "Why Private Health Insurance Must Fail." Kennedy wrote:

We can no longer afford the health insurance industry in America, and we should not waste public funds bailing it out.

There is no place for profit-making and competition for profits and high salaries in health insurance. These motives are at the root of the failure of the health insurance industry to offer adequate protection to Americans and to assure that the health care system is responsive to America's needs.

Even if we provided comprehensive government programs for the insurance industry's biggest problem cases—such as the poor the disabled, the elderly, those with chronic diseases—and even if we wrote and enforced complex government regulations to reduce the gaps, exclusions, and other traps in private insurance [as the current health reform bills do], the insurance industry still could not bring about change in the health care system to control costs, improve quality, and offer health care services in a way most acceptable to the people. The industry would remain a moneychanger taking a percentage of our dollars for a dubious service.

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No American politician could say such things today without being pilloried. Ironically, though, most of the problems Kennedy observed when his Senate subcommittee held the 1971 hearings that became the basis for this book have grown considerably worse today. A sampling:

  • "For the 41.5 million Americans who paid $1.9 billion for individual health insurance with commercial carriers in 1969, the industry took 49.2 percent for 'overhead' or profit." Presumably this means the industry that year paid out 50.8 percent of its premium dollars in claims. In congressional testimony this past June, industry whistle-blower Wendell Potter described one Houston employer that discovered its health insurer paid out only 9 percent of premium dollars in claims in 2006. At the time, the insurer was demanding a 22 percent rate increase.
  • "When Americans who can pay little or nothing for care are struck by illness or accident, they have two choices. They can seek treatment from private hospitals and physicians at the risk of being turned away because they cannot pay or they can seek free care from a city or charity hospital where care is frequently demeaning and inadequate." Since 1972, public and charity hospitals have largely become a thing of the past; between 1990 and 2000, the number of state and locallyowned hospitals in the U.S. declined by nearly 20 percent. Demeaning and inadequate care is vastly preferable to no care at all.
  • Kennedy quoted his Democratic colleague Sen. Harold Hughes complaining that when he was governor of Iowa "I tried to call a physician for my son-in-law … and could not get a physician to go to his home to see him when he was suffering some severe cramps and intestinal distress." To readers under the age of 40, let me explain: For much of the 20th century, American doctors performed what were known as "house calls." Individuals who were sick were thought too uncomfortable or fragile to be transported to doctors' offices or to hospital emergency rooms, so the doctor traveled to the patient instead. The practice ended entirely two or three years after Sen. Hughes lodged this complaint.
  • "The attraction of high income may also account for the fact that of the 278,000 physicians practicing medicine in 1970, some 28,000, or more than 10 percent, were general surgeons and 82,000, or almost 30 percent, were in one or another of the surgical specialties." Since 1977, the percentage of medical students going into primary care has declined by 52 percent.
  • "[H]ospitals effectively control Blue Cross managing boards." In those days, Blue Cross/Blue Shield insurers were typically nonprofit. Today, they're typically for-profit, and stockholders effectively control Blue Cross managing boards. Bring back control by hospitals!

I'll grant that in a few respects access to health care has improved. For example (and in large part thanks to Kennedy) employees who lose their jobs may compel their companies to continue providing health insurance for a limited period of time. More low-income families are eligible for government health insurance through an easing of eligibility requirements for Medicaid (these would be eased still further under health care reform) and the establishment of the State Children's Health Insurance Program (another Kennedy initiative). Medicare now covers drugs, however imperfectly. And, of course, there have been many extraordinary advances in medical science since 1972.

On balance, though, I am more struck by the many ways that over the past 37 years decent health care has become more elusive, not less. Yet our proposed solutions have become much more modest.

Timothy Noah is a former Slate staffer. His  book about income inequality is The Great Divergence.

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