We are approaching the 77th anniversary of FDR’s Four Freedoms speech before Congress. In addition to citing First Amendment rights, he advocated freedom from fear (of the violence and chaos of war) and from want—for everyone in the world. It was an aspirational statement backing his vision of a United Nations. Freedom from the insecurity of poverty was a recurring theme in FDR’s speeches. He challenged governments to provide economic opportunity, social security, and adequate health care.
Presidents died needlessly early -Three years later, he died of a cerebral hemorrhage. He died because of high blood pressure. There was no effective treatment for it, nor any consensus among the medical establishment about the urgent need to treat it. There was no vaccine against polio, which at age 39 ended his life as a totally independent, ambulatory person. Other presidents were victims of medieval or non-existent (but now routine) medicine. Washington died of bloodletting. In office for four months, James Garfield, reputedly one of the great minds among our presidents, died of infections conveyed by doctors’ non-sterile explorations of his modest gunshot wound. William McKinley died of an abdominal gunshot wound because intravenous hydration and nutrition did not exist. Hundreds of thousands of soldiers in the world wars died for the same reason. I was born seventeen months after FDR died. While public health agencies made wonderful advances in the first half of the twentieth century, the dawning relevance of medical practice to everyone happened during my childhood. The expansion of antibiotics including anti-TB drugs; the discovery and use of cortisone, anticancer drugs, and long-acting insulin; and the advent of open heart surgery and pacemakers—all occurred by the time I reached middle school. Since then, the value of personal medical care to the average citizen has grown exponentially.
When early social safety nets emerged in Europe at the end of the nineteenth century, sickness insurance was primarily intended to maintain income rather than to cover medical expenses. Even death benefits—lump sum payments to survivors to cover funeral and short-term living expenses—were considered more important than health insurance. And why not? Death was all around, and doctors were mostly powerless to stop it. The best they could do was attend and prognosticate.
Expensive medical costs - By the time FDR was first elected, and despite the continuing futility of most medical care, there was a general appreciation that medical costs for workers were now exceeding the costs of lost income due to sickness. A consortium of major philanthropists assembled a blue ribbon panel that issued numerous volumes of documentation advocating government support of health insurance plans.
But the Social Security Bill of 1935 did not contain provisions for compulsory national health insurance because the core of the bill—income support— was itself novel and costly. Opposition by physicians was also an important factor. By the 1938 mid-terms, conservative successes marked the end of the progressive era. The National Health Act of 1939 that would have funded federal grants to states never had a chance of passing.
FDR’s death—premature by today’s medical standards—lends some irony to his failure to add “adequate health care” to his legacy. Harry Truman worked diligently on a truly universal national health plan, but was done in by anti-Communist rhetoric directed at “socialized medicine.”
Looking back at those times, I feel we were closer to achieving a consensus on how to achieve simplicity and equity in the distribution of health care than we are now. What is weird about this is that personal health care, because of its ever-increasing efficacy, is not only more important to us as part of our safety net portfolio, but is also surreptitiously merging with public health. Taking care of individuals with common chronic illnesses according to proven strategies is saving money and stabilizing society in the same way that immunizing and killing mosquitos and piping clean water saves money and stabilizes society. We all suffer when we ship some of our fellow humans back to the nineteenth century.