Health Care in the Early 1960s Rosemary A. Stevens, Ph.D. My topic, health care in the early 1960s, comment from a visiting delegation from has a double set of meanings for me. I am a Britain in 1960 were complete air condi- historian, and the 1960s are now "history," tioning and artificial lighting systems, ad- ripe for new interpretations. Yet I was also justable electric beds, carpets in private an immigrant to the United States in 1961, rooms, pass-through refrigerators in the fresh from working as an administrator in kitchen, central milk kitchens, central ster- the British National Health Service. The ile supply services, automatic X-ray proces- period immediately before the Medicare sors, autoanalyzers in the laboratory, plas- legislation in 1965 shines in my memory tic bags for blood, identification bracelets with the vividness of new impressions: for patients, pneumatic tube systems for those of a young health care student trying communications and, not least, massive to make sense of the U. S. health care sys- power plants (Hurst, 1960). In the United tem, and indeed, of the United States. States, the hospital was readily compared The health care system and the United with industrial corporations. States as a society stand, in many ways, as Yet the gaps and variations in both rheto- proxy for each other, now as then: The ric and service were extraordinary. To the whole tells you much about the part, and new migrant, the vast cross-continental the part about the whole. In the early network of superhighways appeared to 1960s, health care was already a massive connect cities-indeed swept through, enterprise. By the late 1950s, hospitals em- around, or over them-without stopping to ployed far more people than the steel in- recognize their problems, character, or dif- dustry, the automobile industry, and inter- ferences. Similarly, in both the larger soci- state railroads. One of every eight ety and the smaller domain of health serv- Americans was admitted annually as an in- ices, there were searches for a unifying patient (Somers and Somers, 1961). To common purpose, overlying conflicts and study health care, with all its contradictions ambiguities. Great leaders defined heroic, and complexities, in the 1960s as in the rallying causes: John F Kennedy, Lyndon present, is to explore the character and am- Baines Johnson, Martin Luther King, Jr. biguities of the United States itself, that Yet the structure and financing of the vast, brash, divided yet curiously hopeful health system made little intuitive sense. Nation. More than 70 percent of the population had On the face of it, the United States was a some form of hospital insurance by 1965 country blessed by plenty in the 1960s, (though less than one-half of the elderly with hospitals and professionals that were population did), 67 percent had surgical in- the envy of the world. Among the marvels surance, and there was a growing market of modern hospitals that provoked for major medical insurance (Health Insur- ance Institute, 1980). But few were insured Rosemary A. Stevens is Professor of History and Sociology of Science at the University of Pennsylvania. The opinions ex- for primary or out-of-hospital care. Of the pressed are those of the author and do not necessarily reflect members of the general population who re- those of the University of Pennsylvania or the Health Care Financing Administration. ported they had "pains in the heart," 25 HEALTH CARE FINANCING REVIEW/ Winter 1996/Volume 18, Number 2 11 percent did not see a physician (Andersen for the potentially catastrophic burdens of and Anderson, 1967). hospital and doctors' bills. The elderly were particularly hard hit. Government programs were segmented The classic example of the proposed Medi- into programs designed for apparently "de- care beneficiary was the elderly school- serving" Americans, notably veterans and teacher, blameless after a career of work. "I Federal employees, and for different cat- am one of your old retired teachers that egories of the poor, State by State, who has been forgotten," went one story in con- were by definition "less deserving." Social gressional hearings in 1959: class, like race, was a topic to which many health practitioners had as yet given little I am 80 years old and for 10 years I thought, although the topic had important have been living on a bare nothing, ramifications, both for clinical practice and two meals a day, one egg, a soup, be- for national politics. As one contemporary cause I want to be independent. doctor pointed out, "lower-class" patients I am of Scotch ancestry, my father were often dissatisfied with their medical fought in the Civil War to the end of care and "many of them would prefer gov- the war, therefore, I have it in my ernment medicine" (Storrow, 1963). They blood to be independent and my dig- were also, he wrote, easily angered, per- nity would not let me go down and be haps "physically aggressive when aroused," on welfare. expected frustration from those in author- And I worked so hard that I have per- ity, and tended to behave in unexpected nicious anemia, $9.95 for a little bottle ways. But for the poor, the impersonality of liquid for shots, wholesale, I couldn't and rudeness of large hospitals were often pay for it (Subcommittee on Problems deterring factors in seeking care at all. The of the Aged and Aging of the Commit- rift between doctor and patient was evi- tee of Labor and Public Welfare, 1959; dent, and nineteenth century attitudes Corning, 1969). toward poverty lingered among the more affluent in general. At least one-third of the Members of the initial Medicare popula- population said, when polled in 1963, that tion, born in the late nineteenth century, an individual was personally responsible had survived two world wars, a major eco- for his or her own poverty (Schiltz, 1970). nomic depression, and enormous changes By 1960 though, there were notable shifts in the organization of work, mass produc- toward medical care for those of retire- tion, rapid urbanization, and modern com- ment age. Recognizing the special eco- munications. As beneficiaries of the 1935 nomic needs of the elderly, the Kerr-Mills Social Security legislation, they were mem- Act of 1960 established a new category of bers of a culture of entitlement. By 1964, 83 "medical indigence" for beneficiaries of percent of the population 65 years of age or Federal grants to the States for the elderly. over were eligible for Social Security ben- Legislation for mental health in 1963 tar- efits; and there were almost three times as geted another previously stigmatized many aged Social Security beneficiaries group-a major step toward de-institution- as there were 10 years earlier.' Yet before alizing the mentally ill. The health system Medicare there were no entitlements seemed full of exceptions, exclusions, and contradictions, while national leaders ' Not all those who were eligible for benefits received them; the comparable figures were 63 percent in 1960 and 74 percent in stressed high-sounding, unifying social 1964 (U.S. Department of Health, Education, and Welfare, 1965). principles. 12 HEALTH CARE FINANCING REVIEW/ Winter 1996/Volume is, Number 2 John Kenneth Galbraith (1958) had filled with contrasts. The flight of relatively come up with one apparently unifying argu- young, affluent, middle-class families to ment when he labeled the United States new suburbs created inner cities with dis- "The Affluent Society." In theory, Ameri- proportionate numbers of elderly and mi- cans were now all "middle-class consum- nority Americans. The stage was set for ers," with standard expectations. Televi- summers of racial violence, urban decay, sion, the new vehicle of mass culture, and declining tax revenues for city schools, celebrated modern medicine as part of a hospitals, and social services. In cities such culture of consumerism. All three of the as Newark, New Jersey, and Washington, major television networks carried hospital DC, African-Americans represented a ma- dramas in the early 1960s, centering jority of the population by the early 1960s. Americans in the fictional worlds of Doctor Physicians migrated to the suburbs with Kildare (NBC), Ben Casey (ABC), and the other white-collar workers, leaving the hos- Nurses (CBS). The main issues for health pital emergency room as a primary source policy in this context were to define needy of care for many urban dwellers. Emer- groups as middle-class and to ensure that gency department visits increased by 16 they could behave like middle-class con- million, or 175 percent, between 1954 and sumers by having the means to do so, that 1964, and the quality of care was often is, by having adequate hospital insurance tenuous. Among the complaints: Physi- coverage, backed up where necessary by cians were overworked; they were reluc- public assistance. tant to take on weekend and evening duty; Yet, as sociologist Michael Harrington and as suburbanites beset by worsening (1962) demonstrated eloquently in his own traffic conditions, they could not respond best-seller in 1962, the highest mass stan- promptly to emergency calls (Silver, 1966). dard of living in the world was definitely Wider social rifts permeated the struc- not shared by all. There was "another ture of health care and its institutions. America": 40 to 50 million citizens who These too were often socially "invisible"; were poor, who lacked adequate medical that is, taken for granted and commented care, and who were "socially invisible" to on rarely until the late 1950s. Herbert the majority of the population. Within this Klarman (1962) did a study of hospital pa- poverty-stricken group were more than 8 tients in 1957 that described the rigid pat- million of the 18 million Americans who tern of stratification and segregation by were 65 years of age and over, suffering class and race in New York City.