The Neglect of Everyday Life
Pouring new money into old institutions; housing and health care
The History of Urban Housing and health since 1920 is a history of both arrested development and rapid growth. Our twentieth-century campaigns for social justice have failed to redress the inequalities characteristic of the industrial metropolis. Yet despite this social and political lag the city itself has continued to grow and to change with the unfolding of the national economy so that in our own time it confronts a twofold crisis. On the one hand we continue to struggle with the old issues of sufficient diet, decent housing, adequate medical care, and a safe environment for the lowest third of our citizenry, while at the same time new demands, called forth by the conflicts and expectations of a high standard of living, bureaucratic work, government services, and suburban living, pour in upon the city. The new metropolises and megalopolises of the post-1920 era are both the weary settlements of unanswered poverty and the conflict-ridden arenas of mass luxury and privilege.
The full reasons for the arrested development of housing, health, and other American social programs demand sustained political analysis for explication, but two obvious trends suffice to frame the past half century. First, the late development of the labor movement, legitimized only in the mid-thirties, and the consequent failure of the labor and urban reform movements to coalesce have contributed to the heavy middle-class bias of our urban programs and weakened all attempts to
serve the lowest third of the population. Second, the preoccupation of the nation and its leaders with great national crises, first the Great Depression and then a continuing series of hot and cold wars since 1941, has distracted the nation's talent, energy, and wealth from the tasks of building a humane and just urban society at home. In the last three decades we have systematically neglected the needs of everyday life for a national career of war and imperialism.
Although we had wealth enough for full employment and a living wage for all able-bodied citizens, although we had plentiful resources for the world's most ambitious public-housing program, although we had educational and research institutions aplenty to seek new drugs and therapies while also manning a full complement of institutions for acute, chronic, and preventive care, we did not do any of these things. All our social programs that touch urban life have been tentative, held to experimental levels for long periods, and when finally adopted as permanent national programs they have been underfunded and extended only to a small fraction of the population they ought to serve.
A brief list of the angry groups in today's television news recalls the dual nature of the urban crisis: blacks, working-class whites, middle-class women, soldiers, students, and suburban homeowners. If there were but a single environment with a single set of problems, the energy behind the grievances of these groups would long ago have transformed the politics and programs of the nation. But blacks and many working-class white families suffer the old failure of the city to deal with racism, full employment, adequate wages, and decent housing and health care, while the women, soldiers, students, and homeowners suffer from the new failure of the society to deliver on the promises of its wealth and freedom.
The present generation of Americans thus confronts a double burden—it must solve the old job, food, health, and shelter problems while simultaneously addressing itself to the conflicts and potentials of an extremely wealthy, bureaucratic, mechanized society. This arduous task compounds so many ingredients. White racism, mass middle-class privilege, and elite class power are milled together with the interdependencies of a high-energy, high-technology, thoroughly urbanized society. If the task is vigorously undertaken, the society should be able to catch up with itself by ending the old injustices and should also be able to keep pace with the ever-unfolding sets of problems and possibilities that urban and economic growth will bring. At the very least our present
situation is much improved over that of 1920: the nation is now much wealthier, and we have the benefit of knowing what remedies to take because we can learn from the experience of the partial programs undertaken during the past half-century. The most severe test now, as always, is the question whether the public and its leaders are willing to shoulder the burden of ending the failings and injustices of the system.
In terms of housing the United States already operates a sufficient range of public programs to redress the grievances of the bottom third of the urban population while simultaneously adapting to the new possibilities and demands of the more prosperous two-thirds. Together, the major housing and planning devices of insured mortgages, subsidized public housing, and urban renewal could transform our cities. For the past thirty-five years, however, underfunding, narrowly circumscribed and antisocial goals, and plain bad administration have prevented this set of tools from relieving our metropolitan-wide housing crises. Indeed, rather than aiding the modernization of our cities and enlarging the inclusiveness of our society, these programs directly interfere with wholesome metropolitan growth and pile governmental injustices upon the heap of private prejudice and exploitation.
The most successful and largest of all the public measures has been the national mortgage-insurance program. Born of the banking crisis of the Great Depression, the Federal Housing Administration's mortgage insurance quickly assumed a major role in helping marginal buyers to homeownership because it fitted in so neatly with the existing organizations of private moneylending, construction, and sales. Since its first full elaboration in the late thirties, FHA mortgages have covered about a fifth of all the privately owned nonfarm housing units of the nation. During World War II and the recent money shortage the federally insured fraction rose to 45 percent and 35 percent respectively.
The circumstances surrounding these programs' origins determined their subsequent history. In 1925 the post—World War I housing boom began to slacken as private capital took flight from mortgages to seek higher returns elsewhere. As a result the costs of housing rose and the number of building starts declined steadily as more and more thousands of American families on the margin of home purchase were squeezed out of the market. The financial collapse of 1929 then delivered a final blow to an already weakened building industry. National banks and trust companies emptied their mortgage portfolios to cover depositors' runs on cash accounts. Savings banks and building and loan associa-
tions, institutions which specialized in home mortgages and which lent money for long terms, typically for fifteen years, found themselves in deep trouble. The savings and loans, however, possessed important political assets. They could and did pose in Washington as innocent local small businessmen, the friends, neighbors, and servants of hard-pressed homeowners, and thereby received prompt and sympathetic action from the national government. In 1932 the Home Loan Bank Act stemmed part of the banking crisis by establishing twelve regional banks for the purpose of lending money to the 12,000 savings and loan associations across the country, thereby preserving the assets of their twelve million depositors and saving the 7,700,000 mortgages on which they had made loans.
Yet the financial collapse was so deep that during 1932 and 1933 mortgage foreclosures continued unabated, reaching a peak of a thousand a day. This prolonged crisis made irresistible the pleas for an extension of aid to all banks rather than to just savings and loan companies. At the same time the extreme pressures of unrelenting unemployment (half to two-thirds of the unemployed males were workers in construction and related building-materials industries) fused in official government thinking the plight of homeowners, bankers, and the unemployed. This fusion brought forth the New Deal housing program—mortgage insurance to aid the banker and the homeowner and federally subsidized construction of public housing to increase building trades' employment. A set of remedies addressed to national economic problems, these measures have powerfully affected the growth of American cities ever since.
First as a bankers' program, the giant FHA loan system had a decidedly conservative charge: it was to concern itself with investments which were economically sound by the current tests of the private market. It was thereby to limit its social reform to aiding the lower middle class and upper working classes in their attempts to borrow money for homeownership or to aid that large segment of the population by guaranteeing the mortgages of builders of apartments and rental units in an appropriate range of rents. Though the total volume of FHA activity had tremendous and enduring impact upon the American city, most particularly by hastening the flight of the white middle class from the central city, open and formal concern for social reform was shunted
to other departments of government. The New Deal generally, and the FHA in particular, fully accepted the racial practices of the private society. The FHA always stayed away from the inner city and gray areas and it even connived with fire insurance companies in their refusal to insure housing in black slums. Far from leading, it tagged behind in racial change. Thus it was not until a year after the Supreme Court decree of 1948 declaring racial covenants on land unenforceable that regulations were promulgated forbidding the issuance of new insured mortgages on such property. Only on November 20, 1962, did a reluctant Kennedy administration issue Executive Order 11063 directing all departments of government to take affirmative action against racial discrimination. For the mortgage market this order meant a timid enforcement of a FHA prohibition against new mortgage money for segregated housing developments.
Extreme caution has also marked the standard-setting functions of the agency. As a partner of private bankers, the FHA has not conceived its role to be that of the protector of the mass of mortgage borrowers, and it has therefore never pressed the consumer's interest in lowering fees for title searches, extra bank charges, and lawyers' services. A similar tendency has characterized the agency's construction and land-planning policies. Quite naturally the first concerns of the FHA were to see that mortgages it insured rested on houses that conformed to the current consensus for adequate construction, and periodically these specifications have been reviewed to keep pace with changing fashions in housing. Yet the structure itself, as miles of decayed inner-city neighborhoods and half-finished and ill-equipped new suburbs witness, is at most half the cost of a decent home. The landscaping, drainage, streets, utilities, shopping centers, schools, hospitals, clinics, playgrounds, parks, public transportation, and highways require an investment at least equal to, if not far in excess of, that in the dwelling unit itself. Moreover, in the long term, say the thirty-five-year term of a FHA mortgage, the quality of these public services has more to do with the sustained value and utility of a house than do minor variations in its quality. Yet the FHA has not moved far toward using its power of awarding or withholding credit to
influence the coordination of public services with land development at the expanding edges of our metropolitan regions. Overcrowded schools, inadequate drainage, poor street and highway layout, and bad siting of structures are the hallmarks of the lower middle-class and working-class suburbs financed by the agency. The "tickey-tackey" of our new metropolitan regions, to use the current snobbish phrase, is more the product of inadequate public services and bad land planning than poor building practice.
The local-bank focus, especially the local savings and loan association focus, of the federal insurance program also hampers its promotion of good vacant-land development. The local savings bank is the principal supplier of credit to the small underfinanced builder who assembles a parcel and runs up a few houses for quick turnover. The added efforts of such builders (those building less than twenty-five houses a year) contributes approximately two-thirds of each year's new suburban construction. Yet such men have neither the capital, interest, nor political power to plan large-scale coordination of public and private facilities. As a result, federal insurance underwrites a series of small ventures whose combined effect is rapid urban growth, but rapid urban growth at a standard far below the capability of the total capital invested in land, mortgages, and public facilities which this work requires.
In sum, the FHA mortgage-insurance system and parallel Veterans Administration programs have proved tremendously helpful to the emerging middle-class families of America, although they have not served this class nearly as well as they might. The very fact that 60 percent of metropolitan dwellers occupy homes that they own testifies to the popularity and success of the strategy. The plentiful financial resources and high volume of construction which the American housing industry periodically attains have inspired much envy in European countries where chronic housing shortages persist. With our federal
mortgage insurance and concurrent interest and property-tax deduction, which subsidize the middle- and upper-income home buyers and co-operative-apartment owners, we have pushed the limits of massive government assistance to private housing. As a nation we have reaped the full benefits of a trickle-down housing market: no severe housing shortages for the upper two-thirds of the urban population and rapid new construction for the upper half.
Not only has the great mass of working-class successors to secondhand housing benefited; even the poor can count some gains. The decline in density of most areas of the inner city brought about by the rapid distention of the metropolis has meant that the greatest part of our city dwellers can now afford private housing without doubling up. Thus, except for the worst black inner-city ghettos, city apartments meet the occupancy rules that were first laid down about 1900, and single-family and two-family homes in run-down neighborhoods can be used as such by low-income families without the need to take in boarders or share with other families. This drop in crude density also ramifies through many aspects of public health: it reduces the dangers of contagious diseases; it gives the poor some of the personal privacy that hitherto had been a luxury of middle-class life; it makes housekeeping easier and neighborly neglect or sloppiness of less consequence. Finally, with the decline in density the buildings themselves last longer, even though repairs may be neglected. The poor can now use up their structures with a lower rate of decay than in earlier times of overuse.
The social costs to the city and the nation, however, have outweighed such benefits. FHA conservatism in land planning has meant the laying down of thousands of neighborhoods which now must be used for a century whether we like them or not, and they are neighborhoods which failed to meet the best commonplace standards of our own time. There is even evidence today that by taking the indirect approach of increasing mortgage credit rather than by building itself, the federal government may unwittingly have inflated building costs to such a
degree that many marginal families it hoped to aid are now priced out of the market. More serious still, government mortgage insurance and tax subsidies have vigorously promoted the racial segregation of the metropolis. The government now faces the herculean task of undoing its own work, of having American city dwellers unlearn the habits and attitudes of class and racial segregation which government policies have been consciously and unconsciously teaching them since 1935. It is a task at which the nation may well falter because of the weight of political habit and precedent which these policies have saddled upon homeowners, tenants, builders, bankers, government officials, and Congressmen. Over the past thirty-five years the nation has grown comfortable, even proud, of its commitment of billions of dollars in tax exemptions and government insurance for the benefit of the upper two-thirds of the population. We have grown accustomed in the housing field, as in so many others, to using government to give the most aid and service to those among us who need it least. Such a habit of government, the very essence of promoting a trickle-down housing policy, flies in the face of a goal of building a more inclusive society. Although aid to marginal home buyers is a useful policy when used in combination with a massive public-housing program, the latter has failed in its purpose because of habits of class greed, racial animosity, and majoritarian self-satisfaction which mortgage insurance and tax exemptions have long nourished. With the upper two-thirds of the population attended to, how was the lowest third to be heeded?
Since 1934 the federal government has administered a small program of housing aid to the low-income families of the nation. Much has been learned from these experiments and past errors have been eliminated by corrective legislation, especially in the basic acts of 1949 and 1968. The requirements for a decent housing program for the ill-housed third of our urban fellow citizens are now known. All the legislative shortcomings, except the correction of the disorders of the local property tax, have been rectified. It only remains for the general public to vote the necessary funds and for the public and its administrators to pursue the task with good will and energy.
Inexcusable class, racial, and commercial antagonisms have dogged American public housing from its inception, and to these antagonisms must be ascribed the most serious and enduring failings of the programs.
Initially prejudice against such work was overcome by the sheer collapse of the construction industry, which served to bring labor unions and urban reformers together. Labor wanted construction jobs, while the reformers wanted to clear some of the slums which they had without avail been trying to exorcise by regulations. From 1934 through 1937 the Public Works Administration of the federal government built 22,000 low-rent units in fifty projects about the country on the make-work justification. Court opposition, a diffuse but nonetheless widespread sentiment that direct federal construction somehow impinged too closely on local government and the sanctity of the home, and fears of real-estate dealers and bankers of price-cutting competition forced changes in the federal participation. Alarm over a monstrous federal bureaucracy was overcome by a grants-in-aid system for the benefit of locally managed housing authorities. Local landlords and real-estate interests were placated by a formula which required that public-housing families must be sufficiently poor so that they could afford rents no higher than 20 percent below those prevailing locally for safe, sanitary shelter. Reformers were given their goal by a provision that for every new low-income unit built, a dilapidated one must be rehabilitated or demolished. Beyond these political bargains the essence of the new program lay in the degree of federal support: the government would contribute the capital sufficient to build the project, the tenants must through their rents pay enough to carry the interest, depreciation, maintenance, and operating costs.
Such a compromise system set some of the long-lasting failings of federal low-rent housing. The support formulas meant that the very poor could not afford to live in public housing because the rents to cover maintenance and management were too high for them. Families whose income rose above the maximum had to leave the projects for private slum housing because of the 20 percent differential which had to be maintained between the top of public housing rents and the bottom of the private market. The rules tying subsidized rent to the personal income of families were so written that if a family's fortune rose its rents could not also float up to fair market values while they continued to occupy their apartment. Instead the most economically successful families were forced out of the projects regardless of their personal prefer-
ences. In Europe the common practice is to allow families settled in public housing to remain and pay market-equivalent rents if they so choose. The 1968 revisions of the federal laws have finally begun tentative steps to end these antisocial income policies.
There have been other unfortunate aspects of our housing program revolving around such issues as lack of tenant participation in project management, harassment of tenants to enforce income and conduct rules, lack of social services and community facilities, neglect of space for large families, poor siting, and so forth. But most crippling of all, because these shortcomings permeate all aspects of public housing from the corridors of the apartment houses to the Housing and Urban Development Department offices in Washington, have been the interacting failures of low-volume construction, segregation, and bad design. Since the goal of the 1949 act of "a decent home and a suitable living environment for every American family" has never been popularly accepted as a right of citizenship either by the victimized poor or the fearful affluent, a terrible incubus of philanthropy has plagued public housing and steadily brings on it cycles of sickness. With public housing perceived as a burden and an expression of charity rather than a right of all and an investment in the human capital of the city, both local and federal governments have consistently scrimped, saved, and limited the program. Underfunding has meant cut-down design programs, high-rise jungles, and low-rise projects which do not even match the standards of World War I workers' housing. When an occasional good design comes forward, it must be built against the weight of bureaucratic regulations and popular prejudices and is rarely imitated. Good architects and aggressive administrators have been driven off by red tape and low morale. As residents of ill-designed and ill-managed facilities, tenants have often felt little responsibility for their quarters and resented the public stigma of institutionalized charity. Underdesign meant that children soon overran such amenities as were provided, with shattered trees, worn-out grass, broken windows, and a periphery of derelict cars confirming the passing citizen's view that "those people" didn't deserve decent housing. As undeserving poor and black citizens, project dwellers must be restricted to the old slum neighborhoods, or as in Boston, be put out next to the city
dump, and not allowed to settle in the suburbs. Thus even after the federal policy of deliberate racial segregation was rescinded in 1949, segregation of public housing has continued because the housing projects we have built in our large cities stereotype the poor and the black in a way that reinforces all the fears and prejudices of working-class and middle-class Americans. Thus underfunding brought poor design, poor design fed segregation, segregation fostered the social and economic failure of projects, and failure justified underfunding. Round and round the cycle went, constantly eroding what was potentially one of the most useful tools of American urban policy.
With the post—World War II FHA-funded housing boom, organized labor lost interest in public housing; those construction jobs weren't needed any longer. Underfunding, bad design, and repeated reports and observations of the social pathology of projects drove off the urban reformers' support. In 1957 one of the most perceptive supporters of public housing, Catherine Bauer, summarized the reformers' dismay.
Public-housing projects tend to be very large and highly standardized in their design. Visually they may be no more monotonous than a typical suburban tract, but their density makes them seem much more institutional, like veterans' hospitals or old-fashioned orphan asylums. The fact they are usually designed as Islands—"community units" turning their back to the surrounding neighborhood which looks entirely different—only adds to this institutional quality. Any charity stigma that attaches to subsidized housing is thus reinforced. Each project proclaims, visually, that it serves the "lowest income group."
Though Congressional support has continued on the momentum of the past, within most large cities opposition to public housing has mounted. Detroit has only 8,200 units and has not undertaken a new project for some years; Philadelphia, Boston, Houston, Los Angeles, and Washington all have under 16,000 units for metropolitan populations well in excess of a million inhabitants. Only New York has pursued public housing vigorously, and the pathologies of that city's projects are accordingly the most visible to the nation. The central city's courtship of the middle-income and wealthy taxpayer puts the final stigma on public housing. After a generation of construction, from 1934 to 1970, only 893,500 units were completed and in operation around the
country. Of this total 143,400 were for the benefit of the elderly. Less than 2 percent of our metropolitan population occupies such structures. Bad as it is, the popularity of public housing tells of the hard choices the poor must make. For most spaces there are long waiting lists. The projects are not catchbasins of abject and defeated poor, but are used by low-income families much as Americans use their private housing. The annual turnover rate, the coming and going of families, is only somewhat less than the general national norm. Finally, because of the relatively small number of units the poor have had to bear the brunt of the social and economic dislocations attendant upon giant highway and urban-renewal land clearances since World War II. In no city did public housing even approach the volume of destruction of the stock of housing from which the poor had to choose.
The 1968 act has ended most of the formal barriers to a decent American public-housing program. If new court decisions in the states reduce municipal dependence upon the local property tax, the last institutional justification for excluding the poor from any neighborhood will be removed. What remains is clear enough. To end the sick self-defeating cycle of low volume of construction, segregation of sites, and institutional design, the public, both the victimized third and the fearful upper two-thirds, must come to think of all Americans as members of one society. They must come to believe that every one of us has a right to "a decent home and a suitable living environment." Surely such a principle is one of the essential elements in a minimum definition of the meaning of an affluent democracy. Once that spirit is accepted, public housing can easily be attached to urban-renewal reconstruction and the building of new towns. Most importantly of all, it can be located on vacant sites in the suburbs and the new centers of our ever-enlarging metropolitan regions. When public housing ceases to be a grudging philanthropy and becomes a goal of granting our fellow citizens their just rights, then projects can be designed to meet the standards of
commonplace American aspirations and to be related to their neighborhoods instead of being isolated from them. Such a program would take time, but steadily pursued for a generation it could close the gap of isolation and punishment of the lower third of the population and enable the poor and the black of America to participate as equals in the new freedoms of our metropolitan society.
Had the United States been pursuing an active and humane public-housing program in the years since 1949, and had urban-renewal allocations been consciously tied to a national urban policy, then urban renewal could have assumed its proper role as the program for the upper two-thirds of the population. Properly understood, the many interrelated programs which go under the rubric "urban renewal" have as their legitimate function the modernizing of our metropolitan regions in a way which will bring them in closer accord to the possibilities of a wealthy and expanding economy. Urban renewal could and should be the tool whereby the prospering elements in the society get a chance to remake the old sections of the metropolis in conformity to national goals for full employment and planned urban and regional growth. Unlike public housing, which now authorizes a very wide range of programs and is sufficient to allow vigorous administration, urban renewal still contains a fatal flaw: it lacks adequate political and policy structure. This flaw, which derives from its historical development, has in large measure accounted for its extremely wasteful and scandalously inhumane practices.
After World War II, an enlarged understanding of the mechanisms of urban growth gained from research and experiments of the thirties and early forties, along with dissatisfaction over the small public housing program, led urban reformers to propose a grand attack on the slums. By 1945 it had become generally understood that the land itself and its supporting public facilities were the key to housing, and experts testifying in extended hearings before Congress urged that the attack upon the slums be redirected toward the land under the structures. The federal government should finance the clearance of slum districts and the assembling of the hundreds of small parcels of land into which such property was divided. For their part, municipalities should administer the program, make use of their powers of eminent domain for parcel assembly, and build new streets, install new lighting, erect schools, and the like. After these steps the public low-rent housing and privately constructed middle-income housing could be erected on the prepared
sites, thereby modernizing great tracts of decayed slums. The essential soundness of the suggestion lay in its focus on urban land reclamation and the division of governmental effort according to the relative resources of the federal government and municipalities. The federal government would be harnessed to the most expensive task, clearance and parcel assembly, while the city would contribute by using its planning offices and its powers of eminent domain, and by constructing supporting services and organizing local support.
Despite its insights and clear intentions, the 1949 urban-renewal legislation ignored the power relationships within the cities which were to carry out the Congressional intent. Rather than initiate a new method for aiding the poor, municipal officials and commercial interests turned the ten-billion-dollar program into an irresponsible social monster. The post-World War II economic boom, combining as it did new metropolitan highway systems, rapid suburban construction of houses, shopping centers, and offices and plants, left the old central cities stranded with billions of dollars tied up in investments in a downtown pattern suited to the streetcar era. Poor whites and blacks streamed into the old cores as the working-class and middle-class whites sought the new suburbs., The poor newcomers, without organized political representation at City Hall, often deliberately excluded from power and political expression, tilted the balance of postwar urban politics. With working-class machines weakened by outmigration of their former constituents, a coalition of inner-city business interests and reform-minded moderates who were unaware of the future consequences of urban renewal, or who wanted to protect their own neighborhoods against the poor and the black, swept into office on urban renewal platforms. Again, as in the current animosity against low-income public housing and even working-class and lower middle-class FHA housing, the metropolitan dysfunction of the property tax played an important role in subverting urban renewal. Mayors, hard pressed for funds because the middle-class exodus cut property values in the central city, sought to use the new federal program to woo back the deserters. They hoped that by rebuilding the downtown core of the cities in the new styles of the day they could lure back wealthy taxpayers and shore up downtown retail sales and office rentals, thereby enlarging the municipality's tax resources. Thus, the low-
rent and public-housing goals of the 1949 legislation were subverted or ignored, and in time conservative Congresses consented to this alteration in favor of the well-to-do. The downtown horse was to be fed to aid the starving municipal pigeons.
Although all past and currently authorized projects will demolish more than a million housing units, almost entirely the former homes of the bottom third of the population who cannot afford any kind of new housing, only 5 percent of the housing in the Community Renewal Projects approved through 1967 will be for low-rent public housing. In the first rushes of clearance, thousands of poor families were displaced without adequate compensation or decent attention to their alternatives. "Negro removal" justifiably became the tag for these programs, and some cities even used urban renewal to force blacks into a single ghetto where previously they had been scattered at several locations about town. The refurbished downtowns, sports stadia, new government and corporate office towers, and slabs of high-rise luxury apartments which typically characterize big-city urban renewal stand in shameless witness to the callousness of American class and race relations. The well-to-do have spent ten billion dollars to redecorate their central cities for their own use and benefit while pushing perhaps a comparable social and economic cost off upon the low-income third of the population. Urban renewal is now a social and political scandal. Its only likely benefit to the poor seems to be its delivery of new capital into the hands of black political groups who are now inheriting the centers of our metropolitan regions. Perhaps they can use these cores as hostages for an increase of their state and federal bargaining power.
In spite of everything, the redevelopment of the old parts of our cities is surely a worthwhile public function; and were the planning and political shortcomings of urban renewal rectified, it could be a useful part of American urban policy. Unfortunately, four key elements were missing from the original legislation and its subsequent administration.
First and most apparent was its callous disregard of the effects of urban renewal upon the living conditions of low-income groups. Rapid construction of public housing in the suburbs could have easily overcome this fault, and since 1967 HUD regulations and subsequent legislation
have been moving in this direction. To date, all the old shortcomings of public housing and virulent class and racial antipathy prevent any substantial increase in the access of the inner-city poor to vacant suburban land.
Second, the long-standing tie between city services and the strength of the local property tax encouraged a socially lethal game of municipal competition for new middle-class and wealthy residents to the exclusion of poor and even working-class families. Successful urban renewal and many other improvements in the American city await the reorganization of metropolitan finances upon some more socially beneficial base. Recent state cases in California and elsewhere, ruling the local property tax an unconstitutional basis for educational taxation, are at last opening up this set of issues.
Third, adequate mechanisms for citizen participation and defense against local projects has not yet been devised. Although successive Congressional enactments called for metropolitan and city-wide planning and for neighborhood consultation, the standards of performance for an adequate project have not yet been made sufficiently definite. HUD's urban-renewal standards should closely reflect the common housing and environmental standards of the nation, and should be stated clearly enough so that local citizens and officials could test their proposals against such goals. The citizen should be able to tell in advance if a given proposal will in fact raise his neighborhood to compliance with the standards of the new suburbs. As in the case of the conflicts between highways and their abutters, should a project fail to meet those standards the affected property owner ought to have standing in court to stop the project until he is guaranteed that it will truly renew his surroundings. As now practiced, urban renewal confronts both the citizen and the planner with mountains of red tape and all the vagueness, delays, powerlessness, manipulation, and profiteering that such procedures inevitably create.
Fourth, urban renewal goes forward in a national policy vacuum. Rather than being integrated with national income and employment
plans and with set goals for regional growth and modernization, it is but another large chunk in the Congressional pork barrel. The Tennessee Valley Authority and the long-continued water, electric, war, and space investments in the Los Angeles region have shown that federal policy can be used to influence the jobs, personal income, private investment, and physical growth of our urban regions. Overseas, European national economic policy has been successfully harnessed to plans for urban and regional growth so that depressed areas, low-income populations, and obsolete cities are benefited through consciously articulated programs for industrial location, transportation improvement, and housing, education, health, and welfare services. As these European undertakings have become effective a new kind of urban and regional politics has developed, commencing an open and wholesome conflict among the affected cities and regions. To neglect such interrelationships between federal programs is to irresponsibly squander the nation's scarce resources. It is our political disgrace that as a nation we could not, and did not, debate a ten-billion-dollar program for the subsidized rebuilding of central-city office and apartment cores in the context of our needs for low- and moderate-income housing, racial desegregation, full employment, medical care, education, highways, farm subsidies, armaments, and a standing army. These are all major undertakings and major concerns of the nation. A decision on one affects all the others, and together they have influenced the growth and present condition of our cities. For urban renewal to become a legitimate undertaking, it must be debated and administered in such a context.
The parallels between American housing and health programs since 1920 are naturally close, since both are integral parts of the same national culture and urban system. Innovations in both have strongly favored the upper two-thirds of the population; both have relied heavily on insurance and tax concessions; both have depended upon local private and public agencies to do their work; both have ignored the poor or served them ill; and both have used large-scale organizations of the central government, banking, and insurance to manipulate the pace and direction of change so that in the name of maintaining the status quo a conservative revolution has been wrought: in housing the dispersal of the old industrial metropolis, in health the near abolition of the solo general practitioner. Finally, after years of divergence, during which
time American medicine concentrated its attention on communicable disease and acute care to the neglect of the larger social issues of class, race, and environment, housing and health are now once more converging as an interlinking set of concerns for the maintenance of a healthy population.
For the vast majority of Americans, altering the death rate is no longer the central health issue. Though there are still highly significant mortality differences caused by race and class position, any truly universal health program whose major foci were preventive care, chronic-ailment care, and the public environment could end such differentials. A 1968 survey of existing Chicago health services defined our modern situation:
Certainly it is a reasonable assumption that timely and proper health care can postpone death from some causes, and prevent, cure, or palliate some diseases. At the same time, however, it is also reasonable to assume that a salubrious environment, only moderately stressful life styles, balanced diet, exercise, good housing, and so on probably have a greater indirect and direct effect on the disease patterns and age at death than do health services as such.
It is the failure of the American health system to adapt to these new conditions, both in its unsatisfactory service to the prosperous and its near-criminal neglect and treatment of the blacks and the poor, that constitutes today's medical crisis.
For the prosperous two-thirds of American society, the history of urban health since 1920 is the history of private medical insurance and the effects that this new mode of payment has had upon the inherited structure of medical practice. In the first years of the era, systematic social and economic research established with certainty that the expense of illness could be insured. The U.S. Public Health Service did a study of the incidence of illness in a small Maryland city during the years 1921-24. Three years later this pilot study was followed by a giant assessment, funded by a number of foundations, of the national incidence of illness, family medical expenses, the incomes of health-service personnel, the nature and distribution of health facilities, and related subjects. The final twenty-eight-volume report of the Committee on the Costs of Medical Care, issued in 1932, showed that insurance was
definitely feasible. The burden of the costs of care fell heavily on a very small fraction of the nation's families in any given year. The reporting committee was divided on the issues of how this insurance should be funded and how it should be related to the provision of medical service. The majority favored government insurance to protect all Americans and proposed that health care be centered in groups of doctors working as teams through hospitals. They saw the hospital as the institution best adapted to the benign management of the increasing specialization and complexity of technique. They objected to privately funded insurance on the grounds that it would offer an insufficient check on doctors and hospitals and therefore would encourage the inflation of medical costs. An accurate prediction!
On the other hand, the minority report better captured the mood and traditions of American patients and physicians, and for its part foresaw the basic flaw in the hospital strategy. Solo general practitioners were already a declining, though still preponderant, fraction of the profession, and the minority felt they should be encouraged as the best hope for ordinary family needs. They estimated that 82 percent of all illness could be competently treated by a well-trained solo practitioner who possessed simple equipment. The dissenters stressed the desirability of individuals' being able to select their personal physician and stressed the efficacy of sustained personal relationships. Group practice and hospitals, as advocated by the majority report, seemed to be applying inhumane big-business and mass-production techniques to human needs. So they proved to be. In keeping with its focus, the minority called for private nonprofit insurance to be managed by the professionals themselves. In short, they endorsed what was to be the wave of the future—the Blue Cross and Blue Shield approach to payment for medical service.
Unfortunately for us all, however, history gave neither side the arrangement it wished; we got instead the worst mix of both. The majority never saw the rise of adequate government insurance or widespread group practice, while the minority lived to see the hospital and specialist trend they deplored accelerated by private insurance. Like the
U.S. government's FHA mortgage program, a creature of depression and threatened bankruptcy, the nonprofit hospital-insurance system worked a conservative revolution upon established patterns by pouring money into the established acute-care hospitals of the nation.
Historians trace the lineage of Blue Cross, the parent hospital-insurance organizations, to 1929 and Dallas, Texas, where Baylor University Hospital took over a local schoolteachers' sick-benefit plan and began to enroll other groups in the city for insured service at the hospital. The example might not have spread far had not the Great Depression undermined the finances of big-city voluntary hospitals everywhere: wealthy donors cut back their giving and patients simply stopped paying their bills. It has been estimated that during one depression year 60 percent of the hospital services in Philadelphia were rendered without any reimbursement. Desperate hospital administrators seized upon the Baylor example and other early experiments, so that by 1932 clusters of city hospitals were banding together to form community-wide insured hospital-service plans. These groups in turn secured appropriate state insurance legislation, developed standard administrative practices, and emerged prior to World War II ás the regional and state-wide Blue Cross insurance companies in the form we now know them.
A few particular arrangements give Blue Cross private-insurance programs their distinctive quality. The companies are nonprofit and are managed by boards of directors who represent the participating hospitals, the medical profession, and community leaders. Their salesmen are salaried, not paid on a commission basis. The companies endeavor by seeking wide participation so as to pool all the medical risks of the state and its cities in order that rates for members who join as individuals do not exceed by too far the rates of those who enroll all together as a group of employees. Finally, Blue Cross plans are not primarily cash-indemnity plans but service plans. The participating hospitals agree to render a specific list of services to members for a fixed fee. The hospital is reimbursed by the insurance company, not the patient. These modes of governance and payment, originally conceived to avoid doctors' reactionary laws against the corporate practice of medicine, proved to have important consequences as the insurance system spread, principally
by making Blue Cross the prisoner of its hospital beneficiaries, not the representative of its patient-members. Well established by 1938, the subsequent wartime boom and the influence of wartime wage controls, which favored rewarding employees with noncash benefits, transformed this Depression defense into a mass institution. By the middle of the fifties, hospital insurance—Blue Cross and its commercial competition had become a fact of life for regularly employed urban Americans.
Blue Shield insurance, a similar set of arrangements for reimbursing participating doctors for a specific list of surgical procedures, had a different origin from Blue Cross, and quite different rationale. Its secondary goal was to rescue doctors from unpaid bills, while its primary goal has been to defend private practice against public demands for government insurance. The ancestors of Blue Shield first appeared on the Pacific coast around 1917, when county medical societies in the states of Washington and Oregon organized prepayment service as an alternative to the current unscrupulous contract practice then prevalent in lumbering, mining, and railroad communities. At that time employers in these isolated settlements were paying for medical services to their hands, but often the patients received scandalously low-quality treatment.
The Great Depression and a threat by the governor of California to press for compulsory insurance carried such plans down the Pacific coast and across the nation. Originally such plans offered a broad range of services, but as they were introduced on a larger scale heavy usage threatened them with bankruptcy and the coverage had to be pruned. The American Medical Association always viewed these programs with suspicion, favoring cash-indemnity insurance for the patient rather than insured services, since the former seemed to sharply differentiate financial matters from practice and hence seemed to threaten less of an opening toward the group medical practice the Association feared. In the immediate post-World War II years, when every Congress debated bills for government medical insurance and President Truman pressed for such measures, the medical profession actively promoted surgical and hospital insurance as its answer to socialized medicine. With a structure similar to that of Blue Cross, often even sharing combined offices, Blue Shield rode the coattails of its more established hospital patron until by the mid-fifties it was almost as widespread, and the two
programs came to be fused in the popular mind as "medical insurance."
Fraught with major limitations as the Blues are—limitations of both governance and coverage—the post-World War II rush of commercial insurance companies into competition with them has exacerbated all the shortcomings of the nonprofit system's effects upon private medical institutions. Although private insurance companies had sold cash disability benefits as extras on their basic workmen's compensation policies for years, the Depression wiped out many company-sponsored employee benefit plans, and commercial insurers were reluctant to return to the health field until the Blues had shown a safe path. In the postwar years a coalition of insurance companies and medical societies defeated the labor-supported government insurance bills before Congress. Rebuffed, the unions returned to the industrial bargaining tables to demand more health benefits for their members. Pressed by such demands and reassured by the booming growth of the Blues, commercial carriers took up group hospital and surgical insurance. Because giant national corporations needed uniform policies for industry-wide bargaining, the largest insurance companies were the best equipped to meet the demand, and soon the top twelve had cornered 90 percent of the business.
Associated differences in mode of payment, rates, and risk pools distinguish commercial policies from the Blues. The standard private carrier's group policy is written for an employer who collects his workers' monthly contributions, if the workers contribute at all, while the insurance company reimburses the employee when he submits his hospital and medical bills. Since most policies today are written with a rate-adjustment clause calling for an increase or decrease in charges based upon a yearly audit of claims, neither the carrier nor the employer has any role in or much incentive to control the quality, quantity, or price of medical services purchased by their beneficiaries. Second, even more than the Blues, commercial policies pool the safest risks and so do not reach out to the most health-endangered populations. As cheap policies, tailored for competitive bidding, commercial insurance skips the old, the irregularly employed, the chronically ill. Moreover, the extent of its coverage depends upon the wit and aggressiveness of union bargaining and does not rest upon a planned assessment of the best deployment of limited health services. At least the Blues seek to build community-wide pools of risks so that individuals may purchase insur-
ance at rates not too far in advance of group charges. The sales and administrative costs of commercial individual policies forbid commercial carriers from following even the Blues' modest lead.
Thus to a remarkable degree the success of the private insurance movement has had much the same effect on the structure of medical services that the FHA did upon the housing market. By establishing insurance pools of safe economic risks, like the safe mortgages, health insurers have extended the purchasing power of working-class and middle-class Americans in such a way as increasingly to neglect the poor, the black, and the old. Moreover, the concentration of policies upon hospitalization, surgery, and catastrophe instead of everyday family needs like dentistry, pediatric care, mental health, and long term paramedical services for both the old and the chronically ill accelerated the pre-existing trends of American medicine toward hospitals, high technology, and bureaucratic doctor-patient relationships.
Complementary policies of the medical profession and the federal government exacerbated these tendencies of mass private insurance. For its part, the medical profession systematically limited the supply of doctors by restricting the output of medical education, thus stifling supply at a time of accelerating demand. Such a monopolistic professional policy inevitably caused a steep rise in medical charges as patients outbid each other for medical attention. At the same time doctors, like all good Americans, competed among themselves for the most lucrative practices and the highest-status positions, thereby rushing headlong toward the most prestigious hospitals, the wealthiest populations, and the most refined specialties.
The government contributed to this flight toward specialized bureaucratic medicine and hospital-based practice in two ways. First, urged on by the successes of national health foundations in tuberculosis and polio research, and beguiled by the seeming political neutrality of research, it poured millions of dollars into research programs, thereby removing doctors from full-time practice and adding prestige to research physicians who contributed little or nothing to meeting the day-to-day needs of the mass of patients. Second, the government invested several billion dollars, starting in 1946 with its Hill-Burton program, in modernizing old acute-care hospitals and building new ones. These federal policies were calculated not to agitate the politically explosive issues of estab-
lished medical practice, but the diversion of billions into research and hospitals had the effect of accelerating the bureaucratization of medical care and the neglect of commonplace needs, central-city services, and low-income groups which the private insurance boom initiated.
Thus, for the upper two-thirds of American city dwellers the trends of private insurance and public policy since 1920 have brought mixed blessings. There is too much emphasis on hospitals and surgery, since these are subsidized institutions and practices; there is too much emphasis on advanced science, technology, and drugs, since these are the traditional successes of American medicine; and there is too much emphasis on the physicians' and other professionals' needs, and too little on the needs of patients. Both insurance funding and the ever-expanding reach of medical science have raised the expectations of Americans as to what constitutes an adequate medical relationship. Yet the screening of physicians from patients by standard commercial hours, overcrowded waiting rooms, secretaries, technicians, nurses, medical centers, hospitals, and insurance forms has poisoned doctor-patient interactions. Middle-class Americans, the former heart of traditional solo practice, have been forced increasingly to use the emergency and outpatient services of urban hospitals, where they encounter the long lines, unkept schedules, lost records, and impersonal and even hostile treatment that the working class has suffered for years. The result has been a partial breakdown of confidence between doctors and private patients, a rapid rise in malpractice suits, a weakening of middle-class opposition to all forms of socialized medicine, and a pervasive feeling of exploitation. Like so many institutions in the modern city, whether nonprofit like universities, schools, and housing authorities, or profit-making like manufacturing corporations, retail stores, and insurance companies, our medical institutions, by expanding into giant permanent organizations without any satisfactory mechanisms for their democratic control by those whom they are supposed to serve, have become mired in bureaucratic self-serving and public malfunction.
Our medical institutions, like so many institutions in America, have a
predominant form, but are not all cast in the same mold. At present a variety of group-practice and insurance systems offer a broad range of alternatives to the regularly employed. None have yet evolved any adequate mode of patient representation, so that should they expand they will do so with all the limitations inherent in professionally managed bureaucracies. California, with its early experience with railroad and mining-camp group practice and its long-sustained population boom and doctor shortages, offers the widest range of alternatives. In addition to a few survivors of the early general-practitioner era and the standard solo doctors with hospital affiliations, the state has nurtured all manner of medical modes, from the informal referrals of a cluster of specialists sharing a suburban medical building to large-scale, prepaid group practice and hospital service.
Two examples can serve to express the range of California medical forms and the potentials and shortcomings which these variations now present: the San Joaquin County Foundation for Medical Care and the Kaiser Foundation Health Plan. The first is an organization which attempts to solve the problems of lack of quality and cost supervision inherent in the Blues and commercial insurance, while simultaneously giving its members the traditional minor consumer protection of free choice of a private physician. The second seeks to maximize the savings inherent in large-scale, well-organized clinic and hospital practice, and to pass these savings on in terms of the widest possible coverage against needs for medical attention.
The San Joaquin plan sprang up in response to competition from the Kaiser Plan. The county medical society formed its own foundation in 1954 to mediate among the private insurance carriers and the doctors and patients in its area. The physicians agreed to a fixed schedule of fees for service, while on its side the foundation offered to certify privately marketed insurance policies if such policies offered the range of benefits it thought appropriate to good family medical care. Families who purchased policies could choose their own physician from the society's list and gain the benefit of regular insurance payments against most medical expenses. The unique feature of the plan, a benefit both to carriers and patients, lay in the foundation's processing of claims for the certified policies. Bills are audited in two ways. Trained accountants review them to determine their validity, and county doctors volunteer their time on rotation to determine the appropriateness of the treatment. In cases of
abuse on either count, the foundation undertakes to negotiate the charges between the physician and the patient.
Although such supervision of costs and quality far exceeds that undertaken by large private carriers, the San Joaquin methods of shoring up the existing system cannot offset the expensive habits of overhospitalization and inefficient allocation of medical personnel's time which is inherent in American solo or informal referral practice. Its conservatism, harking back to the criticisms of the minority in the Committee on the Cost of Medical Care of 1932, does meet a persistent and important charge against group practice. Although crowded waiting rooms, overscheduling, an authoritarian manner, and a bureaucratic style bring many solo practitioners' habits dangerously close to the classic outpatient hospital style, some residual consumer benefits remain in the patient's free choice of his physician. The San Joaquin plan preserves this traditional margin of benefit. Yet since it does not attack either the problems of costs or depersonalization directly it leaves its working-class and middle-class members far from their legitimate goals of cheap, humane medical service.
The Kaiser Plan is a much more ambitious insurance and service scheme. It began in the late thirties with a prepaid plan for workers and their families at the Grand Coulee Dam site in Washington, where Edgar Kaiser was the prime contractor. Dr. Sidney Garfield, who ran the service, noticed that the method of payment had a good effect on the quality of service he and his colleagues gave. Prepayment weakened the habit of thinking in terms of repeated visits and expensive hospital procedures; and with this traditional economic pressure relaxed, both service improved and costs declined. During World War II, Dr. Garfield operated a large medical and hospital service for Kaiser's shipyards in the San Francisco area, and the program was so popular that workers kept up their memberships after the war. In 1952 the Kaiser Foundation Health Plan was established as a nonprofit corporation and burgeoned to serve about one and a half million people in California, Oregon, and Hawaii.
The heart of the plan lies in its fixed insurance charges to members,
which guarantee the widest range of services offered anywhere, the most notable exclusions from the contract being dentistry, psychiatry, and drugs. Patients are encouraged to seek regular relationships with one physician, but there are also walk-in clinic hours when members can be attended to on a first come, first served basis. The foundation also operates its own hospitals and emergency services. In addition to its economies of carefully managed group practice, the Kaiser Plan undertakes systematic review and supervision of its doctors' performance. A special bonus system acts as an incentive against hospitalization, and the foundation has organized home-care teams of physicians, public health nurses, and physical therapists to match its campaign to reduce the incidence of hospital treatment.
Because of its reasonable charges and extensive services, the Kaiser Plan has been extremely popular in the Pacific states. Indeed, shortages of doctors and capital for hospitals and clinics have restricted its growth and forced it to close its membership lists from time to time. Its immediate shortcomings of delays for appointments and inaccessibility of some clinics stem principally from its inability to keep pace with popular demand. Its success and those of similar insured group-practice schemes have led to numerous imitators, most notably by the Hospital Insurance Plan in New York City and labor-union plans in other cities. Although it suffers the general shortcomings of all privately funded programs—it cannot reach its proportionate share of the poor and the old—the Kaiser Plan is often hailed as the ideal model for the restructuring of American medical practice, and for universalization by way of federal subsidies for low-income groups.
If such a policy were to be undertaken either by a state or the federal government (and such a policy seems to be a logical next step), then two basic limitations of the Kaiser Plan must be dealt with. First, the traditional isolation of the medical profession from social and environmental issues must be overcome. In the narrowest sense, new clinics and hospitals must be consciously located in respect to patterns of urban growth and population need. New York State alone uses its licensing powers to plan in this way, but the federal government has
begun since 1966 to move in the same direction, and public supervision of medical-facility location seems an easy step to take. More difficult, yet perhaps more important to the long-run health of ordinary American families, is the need to use the records and experience of physicians as information in the planning of school nutrition, industrial health, and water, air, housing, and recreation planning for metropolitan regions. For the development of subdivisions, where typically homes are built without coordination with the public facilities which make them viable, the day-to-day records of urban families' health experience should be an important determinant of our social and environmental investments. In view of the current high medical and living standards of the upper two-thirds of our population the social and environmental aspects of modern living are the most significant tools for improving the majority's health.
Second, some methods for patient participation in the management or supervision of large-scale health institutions are absolutely essential. The long history of hospitals, especially of hospital outpatient services, and our abundant experience with all manner of bureaucracies show that management left to professionals, no matter how well-intentioned, soon degenerates into a bad mix of self-serving and philanthropy. Although the Office of Economic Opportunity and Model Cities programs for the poor involve neighborhood participation, the working class and middle class have not yet demanded representation in their medical institutions. Until then, and until appropriate forms of public participation are devised, regional hospitals, Kaiser Plans, county medical society programs, and union-sponsored clinics will suffer all the shortcomings of bureaucratic service. Since such organized prepayment programs do seem able to meet the twin needs of moderate cost and high levels of competence so much better than the solo practitioner funded by private insurance, it seems imperative that this form of consumer representation be built into such institutions before they expand further.
For the bottom third of America's urban population, the years since 1920 have been a medical disaster. Put in simplest terms, those with the greatest needs have been getting the least and the worst. All the problems which beset services to the upper two-thirds also bore on this group, and much more besides. The sheer growth of our cities has left them stranded, while the inflationary pressures of the monopolistic
practices of physicians acting in tandem with federal programs have priced millions out of the medical market and left entire core-city populations without access to decent health services. As in the trickle-down housing market, where the ability to obtain adequate housing and to benefit from federal subsidies depended upon a family's having attained an income threshold at least a third above the bottom level, so too access to good medical service and hospital insurance had to be purchased by regular employment and residence in a decent neighborhood. Although since the twenties rapid urbanization, rising living standards, and additions to medical science have markedly improved the health of a giant marginal group of city dwellers, say those in the range from the bottom third upward to the midpoint of the total income distribution, everything conspired against the lowest third's getting its fair share of the benefits of the last fifty years' advances.
Perhaps first and foremost, the growth pattern of the city, intensifying the segregation of white and black poor at the center of the metropolis, had the most damaging effects. The rising geographical concentration of what is now termed the medically indigent exacerbated the division between ordinary private medicine and philanthropic practice which was the legacy of the previous era's establishment. The entrapment of poor whites and blacks in old central cities weakened the tax base of their communities at the very moment when municipal hospitals, dispensaries, and social services required heavy additional funding to meet the legitimate needs of their neighborhood populations. Once again the dependence of American municipal government on the local property tax played its antisocial role. The rich, increasingly dwelling in the suburbs, failed to contribute the necessary capital to inner-city voluntary hospitals; indeed, many shifted their attention to new institutions closer to their homes. The relatively declining core-city tax base meant the progressive neglect of already established city hospitals and clinics. The Hill-Burton hospital building program of the federal government, begun in 1946, accelerated these trends by subsidizing the construction of new suburban hospitals while its contributions to remodeling old central-city institutions at best enabled them to catch up with their own obsolescence but did not in any way direct inner-city medical service to the neighborhoods where the severest crises were occurring. Neither did the Hill-Burton money attack the racism of the established
mixed private and public hospital network. The suburbanization of the upper working class and middle class, the spread of private insurance among them, and the new suburban hospitals all conspired to draw private physicians out of the old neighborhoods to follow the paying patients. Finally, the restriction of output by American medical schools and their deep-seated prejudice against training black physicians completed the tragedy.
Recent Chicago surveys taken even after the Great Society reforms of the sixties tell of the depth and magnitude of our urban health failure. The metropolitan region is characterized by "spatial epidemics" where the core districts of white poverty and black segregation suffer disproportionate infant mortality, tuberculosis, hepatitis, pneumonia, rheumatic fever, venereal diseases, measles, and other illnesses. The morbidity and mortality maps of the city give bitter confirmation to the additive effects of our urban traditions: poverty, social pathology, high-density living, low-level sanitary services, and inadequate or nonexistent medical care combine to make what one student of Chicago's public health has called an apartheid health system. Public neglect of the critical need for full employment at living wages, callous disregard for the maintenance of the physical environment, the punitive practice of welfare and charity medicine, and institutional racism in both public and private health facilities have cumulated in a social disaster for the inner city. Stranded all-white hospitals do not serve their black neighbors for fear of losing their regular physicians' and patients' support, many black families have only mass-production welfare practitioners to serve their neighborhood, white physicians cannot venture into black neighborhoods at night, both the white poor and the black of Chicago travel miles to wait in long lines at the monster Cook County Hospital complex, and they wait there to be seen by a physician who likely as not hardly speaks English. These are some of the commonplace Chicago anomalies, and similar ones exist in every large American city.
The mounting day-to-day count of preventable disease and death accuses the majority of Americans, their physicians, and their insurance companies. Because of their past actions in defeating government medical insurance on the eve of the two suburban booms after the two World Wars, we now face a breakdown of our medical system. American cities should be coping with the task of adapting well-established institutions to new needs. Instead they face a situation where inner-city health facilities cannot carry their load and the private insurance and suburban medical network is insufficiently organized to come to the aid of the inner city poor and black.
Just as in the housing field, where the federal government attempted to get the private market to attend to the needs of the poor and inevitably failed, so in the health field where Great Society programs have attempted to cajole the established health-care system into care of the old, the black, and the poor, it inevitably failed. In both fields excellent small-scale experiments in the United States abounded, but they could not flourish and multiply here without genuine popular support. Until the majority of Americans are willing to accept the standard of a decent home, a suitable living environment, and adequate health care as a right of all citizens, an urgent right that takes precedence over armaments, imperialism, private property, and private profit, public programs will do little more than reveal the basic injustice and social disorders of our unequal distribution of income and services.
The lifeless continuation of charity services and public-welfare medicine, so well demonstrated in the Chicago studies, when contrasted to the robust growth of Veterans Administration medicine after 1945 testifies to the difference between programs of philanthropy and a program of popular rights. The former are chronically underfunded by a wide margin, grudgingly expanded, shot through with incompetence, abuse, and fraud, and periodically reformed by novelties tailored to political crises; the latter is generously supported, rapidly expanded to match the veteran population, as competent as the general run of American medicine, and has been evolving as a set of institutions since World War I until now they offer full health services to all veterans regardless of the origins of their medical needs. The former consist of
a reluctant philanthropy for second-class citizens, while the latter is a patriotic practice of socialism for first-class citizens, a service which treats its clients as well and as badly as American medicine treats the upper two-thirds of our civilian society.
The health-care reforms of the urban crisis of the sixties are therefore, like the postwar housing policies, attempts to deal with the historical unfolding of long-standing urban problems without a popular commitment to the rights of full citizenship, and without a sense of urgency for the demands of everyday life. Instead the impulse for reform was instigated by the national confrontation with white racism, the explosion of inner cities in the riots of the mid-sixties, and the need of Democratic Presidents to seek old people's and black people's votes. Such expediencies brought forward the federally sponsored package of Great Society health-care measures—neighborhood clinics, Model Cities coordinated planning, and Medicare and Medicaid.
The neighborhood clinics sponsored by the Office of Economic Opportunity and other agencies were designed to meet the immediate shortage of doctors in poor areas of the city and also to overcome some of the historic limitations of the old-fashioned hospital and dispensary network. In a typical case, the Mile Square Clinic in Chicago, OEO contracted with a voluntary teaching hospital to serve an impoverished population of 25,000 on the West Side. The hope of the contract device was to draw upon an established pool of high-quality personnel rather than funding a new municipal or state clinic. Since all the clinic employees remain employees of the Presbyterian—St. Luke's Hospital, they can still keep their ties and advancement orientation to that prestigious medical hierarchy. Such contracts seem a reasonable emergency strategy, but the historical record of hospital management of outpatient services demonstrates that it is an unstable form. In time either the hospital will neglect its clinic staff or the staff will neglect its patients. To circumvent the old abuses of dispensary service, the clinic employs local residents and has created a neighborhood advisory council to participate in its management. But neighborhood control will come to naught unless the clinic receives ample and continuing public funding to enable it to attract and retain a good staff. The clinic itself functions by group practice much in the Kaiser Fund manner, and like the California model it
employs public-health nurse teams to give home follow-up care and service.
At present such neighborhood clinics are regarded as the best hope for the inner city. A Chicago study calls for the creation of twenty-four there, and public-health surveys in other cities suggest similar strategies. Thanks to the crisis of the sixties, plentiful examples exist for adaptation to particular city needs. The unresolved issue, however, remains the same as before. Today's clinics are temporary and under-funded, and they are just a tiny fraction of the total required. In parts of the city where doctors are more plentiful but where commonplace services are still in short supply, as in many white working-class areas, such clinics will inevitably face the bitter opposition of a coalition of private practitioners, insurance companies, and medical societies. As in the sick cycle of public housing, the stigma of low-quality clinic service inherited from the past will make it difficult for health reformers to form a coalition among poor, working-class, and middle-class citizens to press for the creation of all-class clinics which would benefit everyone. As in so many fields, the current political equilibrium sustained by partial service to the majority blocks the realization of our potential for building good universal programs.
The Model Cities innovation, launched in 1967, was designed to offset the overly physical City Hall and business orientation of extant urban programs. The federal government held out the tempting carrot of extra subsidies for cities which would establish Model Cities districts where locally elected boards would attempt to carry out a coordinated development plan for housing, employment, health, education, welfare, and public amenity improvement. Nothing less than a simultaneous demonstration of comprehensive, multi-institutional, local planning coupled with local decision-making was to be attempted. Model Cities boldly took on all the lack of coordination of the suburbs in a setting which added all the problems of inner-city poverty. It is still too early to predict what the ultimate outcome of this heroic leap will be if it becomes a permanent institution of municipal government in America. So far it has at least given an effective veto power to some formerly
unrepresented groups of poor people in the inner city. It seems doubtful, however, that without decent federally maintained full-employment, public-housing, and medical programs, and without state reform of the municipal tax base, that local groups, no matter how intelligent, aggressive, and well subsidized, can make much headway against the heavy historical forces which press upon their neighborhoods. Properly considered, Model Cities planning should have followed major federal and state programs in order to guide and check on their local impacts; by itself it cannot be a substitute for national and regional planning.
In 1965, after years of controversy, Congress finally passed a broad health-insurance law (Medicare). It was not a compulsory insurance program for all employed Americans as contemplated in 1916, but a compulsory hospital-insurance fund and a voluntary medical-insurance scheme for those over sixty-five. At the same time Congress voted to liberalize and rationalize its grants-in-aid support for state welfare recipients (Medicaid) in order to guarantee payments for hospitalization and medical service to the poor. Neither Medicare nor Medicaid looked toward any alteration in the provision of services, except for the promotion of nursing homes, and neither demanded any restructuring of the established institutions of medicine. Under Medicare an increment was added to the general Social Security payroll taxes to finance a government hospital-insurance fund which would enable the aged to receive upon retirement the benefits which existing private insurance often denied them. Old people could further elect to make a small monthly payment (now about five dollars) which the federal government would match to entitle them to a broad range of medical service. The principal uninsured items were dentistry, hearing aids, self-administered drugs, immunizations, and physical checkups. Under Medicaid, Congress offered to match states' payments for hospital and physicians' services to welfare recipients if the states passed appropriate enabling legislation. All the states except Alaska and Arizona have now done so. In keeping with the open-ended intent of the statute, the range of benefits and eligibility vary widely from state to state.
Although the passage of Medicare and Medicaid is undoubtedly an important event in the political history of public health in that it allowed
the federal government to break half a century's barriers against national insurance, and although many old people's medical bills have been reduced, and many poor people's chances for attention have increased, the most significant effect of the 1965 legislation may well prove to be its subsequent public exposure of the weaknesses in the structure of the American health-care system. With federal taxes and subsidies increasing the demand against the limited supply, the first effects were to inflate the costs of service. Under Medicare, hospital costs soared to double the first estimates, and the annual rate of increase in charges for physicians' services almost doubled. Since nothing in the statutes increased the numbers of doctors attending the old and the poor or altered the mode of practice by professionals, the long lines at hospitals, mass-production methods of welfare specialists, and the sheer lack of practitioners in central city neighborhoods went unchanged or got worse. Young inner-city mothers and their children continued to suffer all the neglects of charity medicine. Indeed Medicaid engendered a kind of health-care backlash. The inflation of medical charges in state welfare budgets which immediately followed the passage of state enabling acts forced several states to cut back their eligibility and coverage so that the general public was left with the sour impression that the majority could not afford decent medical aid to the bottom third.
Predictably, the attempt of Medicare to find an adequate low-cost alternative to hospitalization of the aged by stimulating the profit appetite of doctors failed. Lured by the promise of Medicare payment for nursing-home service, syndicates of doctors and real-estate investors in every city teamed up to build and to operate such facilities. The gentlest criticism that can be directed toward this policy and its outcome is to observe that the scattering of nursing homes isolates old people and wrongly focuses attention on medical problems, to the neglect of the patients' needs for self-respect, self-care, social life, and participation in the world around them. Comprehensive Jewish charities in many U.S. cities and integrated programs in countries like Sweden have abundantly demonstrated that helping old people to deal with their declining health requires a cluster of institutions ranging from sheltered workshops and recreation centers to home care and hospitalization. It is a measure of
our general society's callousness toward old people, and of the medical profession's isolation from serious concern for the social issues affecting the health of its patients, that together we all consented to a crash program of profit-making nursing homes.
Medicare and Medicaid also had their corrupt side. Doctors bought and sold nursing homes for speculative profit, unscrupulous practitioners took up "gang visiting," rushing through nursing homes collecting Medicare and Medicaid fees as they passed each bed, and drugs and procedures were prescribed and hospital bills padded in the happy expectation that the state and federal treasuries would pay while patients suffered disgraceful neglect.
The spiraling costs, sloppy service, and outright malpractice exposed the social disorders that throve as a result of pouring insurance money and a patchwork of public funds into an unreconstructed medical establishment. In most cases insurance companies, especially the Blues, became the Medicare and Medicaid intermediaries who processed the hospitals' and doctors' bills to pass on for government payment. The mountain of padded bills submitted told more clearly than years of investigations that private insurance companies in no way represented the consumer. They also testified to the fact that despite plentiful hospital and medical representation on their governing boards, the carriers did not see fit to police the profession even to the extent of guaranteeing performance at the levels of the current consensus of standard good practice. The insurance companies functioned solely as collection agencies for their hospital and doctor clients. When the Department of Health, Education and Welfare requested the names of physicians receiving Medicare and Medicaid payments in excess of $25,000 a year, many companies refused to comply.
Thanks to the Great Society attempts to aid the poor and the aged, the long-neglected urban health agenda is now a public political issue. Public-health follow-up studies and OEO neighborhood clinics tell of the tremendous need for commonplace service to inner-city dwellers, the severe inflation of medical costs dramatizes the monopolistic practices of medical schools, the nursing-home failures and scandals speak to the social issues of adequate health care, while the abnegation of supervision by insurance carriers and the long lines and bureaucratic abuses
of big-city hospitals tell of the necessity to reorganize the power balances of medical practice. Once again epidemics, slums, and the suffering of the urban poor have demonstrated to the larger society the weaknesses of its institutions.
Yet in health care, as in housing, a crisis response which is the traditional reflex of our society will miss the essence of the situation and inevitably fall far short of the goal of a humane urban community. The poor are indeed treated far worse than the majority, yet such are the linkages and interconnections of a highly urbanized nation, they are treated worse in the same ways as are those who are comfortably off. The consequences of class and racial segregation which now press so cruelly upon the inner city are part and parcel of the disrespect for commonplace human life, and the denial of full citizenship to blacks, minorities, children, women, and old people throughout the metropolis. The fallen-down buildings, uncollected trash, conflict-ridden schools, grimy hospitals, and bottle-strewn parks are but the frightening evidence of a pervasive neglect of the supporting public services to homes and families which prevails in all but the wealthiest suburbs. The traditional American response is to seek to obliterate the dramatic symptoms while leaving the basic malady untouched. To do so is to repeat once again our long history of failure to build truly humane and inclusive cities. The hope of the American city lies in a public recognition of the interconnections of everyday urban life, and from that recognition to commit the nation to a deep and long-sustained effort to rework its physical and institutional structure.