Beginnings Count: the Technological Imperative in American Health Care

In the wake of the recent unsuccessful drive for health care reform, many people have been asking themselves what brought about the failure of this as well as past attempts to make health care accessible to all Americans. The author of this original exploration of U.S. health policy supplies an answer that is bound to raise some eyebrows. After a careful analysis of the history and issues of health care, David Rothman concludes that it is the average employed, insured "middle class"—the vaguely defined majority of American citizens—who deny health care to the poor.
The author advances his argument through the examination of two distinctive characteristics of American health care and the intricate links between them: the ubiquitous presence of technology in medicine, and the fact that the U.S. lacks a national health insurance program. Technology bears the heaviest responsibility for the costliness of American medicine. Rothman traces the histories of the "iron lung" and kidney dialysis machines in order to provide vivid evidence for his claim that the American middle class is fascinated by technology and is willing to pay the price to see the most recent advances in physics, biology, and biomedical engineering incorporated immediately in medical care. On the other hand, the lack of a universal health insurance program in the U.S. is rooted in the fact that, starting in the 1930s, government health policy has been a reflection of the needs and concerns of the middle class. Playing up to middle class sensibilities, the American presidents, Senate and Congress based their policy upon the private rather than the public sector, whenever possible. They encouraged the purchase of insurance based on the laws of the marketplace, not provided by the government. Private health insurance and high-tech medicine came with a hefty price, with the end result that about 40 million Americans could not afford medical care and were left to fend for themselves. The author investigates the moral values underpinning these decisions, and goes to the bottom of the problem of why the United States remain the only developed country which continually proves unable to provide adequate health care to all its citizens.

Conevery A. Bolton

Historian David Rothman traces the ways in which middle-class demand for high-tech medical interventions has shaped the course of American medicine in the twentieth century. This book grapples with a central question of contemporary American life: how is it that a country with an extremely high level of skilled technological intervention in the ailing human body countenances the vast inequity of access to basic and complex health services? This book will be of interest to medical professionals and historians as well as to members of the public interested in the historical roots of contemporary dilemmas over health insurance, managed care, and the role of the federal government in American healthcare. Six chapters, arranged chronologically, highlight turning points in medical technology, access to health services, and national vs. private responsibility for the expenses of healthcare. Successive chapters discuss the beginnings of Blue Cross in the 1930s, provision of iron lungs in the 1940s and 1950s, debates over Medicare in the early 1960s, federal assumption of the costs of kidney dialysis in the early 1970s, the advent of the respirator in the last third of this century, and the Clinton health plan of the early 1990s. The book's index is useful, and the print quality is good. Rothman's argument is nuanced and historically informed; his writing is clear and straightforward; and his conclusion, that technology in American medicine has been intimately connected with increasing inequality, is thought-provoking and unsettling. Beginnings Count wields a sharp argument, but no bombast. Although Rothman implicitly assails the failure of American medicine to widenaccess to healthcare, especially technological interventions, to those below the ""middle classes,"" he does so in measured arguments and careful prose, backed up by scholarly research and occasionally enlivened by dry wit.