Organized neurosurgery, along with the rest of American medicine, continues to lobby, cajole, and plead its case with the government in order to increase payments by Medicare. Surprising? Probably not. But for those who opposed the adoption of Medicare 40 years ago, these efforts may vindicate their dire predictions.
The creation of some sort of national health insurance was advocated in the early part of the 20th century as an outgrowth of labor and social reform movements. Organized medicine at the time more or less favored the idea. However, state medical societies were against the idea, reflecting the opposition of rank-and-file physicians.
The Depression and President Roosevelt’s “New Deal” lent momentum to the national insurance movement, but FDR himself was noncommittal. A key adviser on his Medical Advisory Committee was neurosurgeon Harvey Cushing, whose daughter was to marry the President’s son soon after. FDR invited Cushing to a private lunch at the White House the day before the committee was to meet for the first time. Cushing was against any major health insurance program, fearing the effects of this governmental control on physicians’ practices and on the quality of American medicine as a whole. In the end no national health insurance was passed under the Roosevelt administration.
The debate on this issue continued through the mid 1960s. The increase in the number of elderly Americans, together with incremental steps that were taken, led ultimately to the creation of Medicare on April 9, 1965. The American Medical Association warned against the huge bureaucracy that would result and the effect on physician-patient relationships. At first doctors’ fees were not part of the plan but then were included as “Part B” of Medicare. The ensuing 40 years have seen ever-expanding federal regulation of physician payments and an increasingly arcane system of coding, documentation, reimbursement, and penalties. And the Medicare program sets the tone for essentially all of the huge American third-party healthcare payment system.
So perhaps the concerns of the AMA and of Harvey Cushing were not unfounded. When asking the government to pay for your services, caveat doctor.
Michael Schulder, MD, is associate professor in the Department of Neurological Surgery and director of Image-Guided Neurosurgery at UMDNJ-New Jersey Medical School.