1. This imaginary meeting is grounded in primary sources and also in an extensive secondary literature that includes the following recent contributions: Daniel M. Fox, Health Policies, Health Politics: The Experience of Britain and America, 1911-1965 (Princeton, N.J.: Princeton University Press, 1986), and "Medical Institutions and the State," in Encyclopedia of the History of Medicine, ed. W. Bynum and R. Porter (London: Routledge, 1993), in press; Kenneth Ludmerer, Learning to Heal (New York: Basic Books, 1985); Charles Rosenberg, The Care of Strangers: The Rise of American Medicine (New York: Basic Books, 1985); Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982); and Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (New York: Basic Books, 1989). The comments on the significance and interpretation of photographs are extended in Daniel M. Fox and Christopher Lawrence, Images and Power: Photographing Medicine in Britain and the United States since 1850 (Greenwich, Conn.: Greenwood Press, 1988). I omit the many important articles in journals from this list, mainly because many of these are cited in the above books. A recent article that is not is John Harley Warner, "The Fall and Rise of Professional Mastery: Epistemology, Authority, and the Emergence of Laboratory Medicine in Nineteenth-Century America," in The Laboratory Revolution in Medicine, ed. A. Cunningham and P. Williams (Cambridge, England: Cambridge University Press, 1992).

2. What follows is based on both a rich literature and personal experience. Among recent books, Stevens's In Sickness and in Wealth is the most pertinent. I have addressed and documented related issues in “AIDS and the American Health Polity: The History and Prospects of a Crisis of Authority," in AIDS: The Burdens of History, ed. Elizabeth Fee and Daniel M. Fox (Berkeley: University of California Press, 1988), and "Betting on Our Nation's Health Policy: With and Without Data," in Proceedings of the 1991 Public Health Conference on Records and Statistics (Washington, D.C.: U.S. Department of Health and Human Services, National Center for Health Statistics, 1992).

3. Starr, in The Social Transformation of American Medicine, summarizes the evidence for physicians' incomes earlier in the century.

4. I have described the close relationship between biomedical research policy and disease in "The Politics of the NIH Extramural Program, 1937-1950," Journal of the History. of Medicine and Allied Sciences 42 (October 1987): 447-66.

5. For a more extensive discussion of ideology as it bears on research on health policy, see Daniel M. Fox, "Health Policy and the Politics of Research in the United States," Journal of Health Politics, Policy and Law 15 (Fall 1990): 481-99.

6. See Fox, "Health Policy and the Politics of Research," for recent literature on using knowledge to inform policy.

7. Stevens, In Sickness and in Wealth, p. 357.

8. Fox, Health Policies, Health Politics, Introduction.

9. Daniel M. Fox, "Health Policy and Changing Epidemiology in the United States: Chronic Disease in the Twentieth Century," in Unnatural Causes: The Three Leading Killer Diseases in America, ed. R. Maulitz (New Brunswick, N.J.: Rutgers University Press, 1989).

10. Sources for these definitions are listed in Daniel M. Fox, "Financing Health Services for the Chronically Ill and Disabled: A History of Political Accommodation," Milbank Quarterly 67, supp. 2, part 2 (1989): 257-89.

11. Ann G. Carmichael, "Human Disease in the World outside Asia: European Mortality Decline, 1700-1900," in The Cambridge World History of Human Disease, ed. Kenneth F. Kiple (Cambridge: Cambridge University Press, 1993), p. 286.

12. M. S. R. Hutt and D. P. Burkitt, The Geography of Noninfectious Disease (Oxford: Oxford University Press, 1986), p. 1.

13. Kiple, Cambridge World History, p. 6.

14. Gerald Grob, From Asylum to Community: Mental Health Policy in Modern America (Princeton, N.J.: Princeton University Press, 1991).

15. Robert J. Maxwell, review of Fox's Health Policies, Health Politics, Lancet, 2, October 10, 1987, p. 828.

16. As I will describe in subsequent chapters, I am merely one among many people who have advocated higher priority for chronic illness. The literature that I have collected on this subject spans a period of almost a century. Advocacy for this position is commonplace at the present time. Specifically, I call attention to the important seminal work of Anselm Strauss in this area. Strauss's articles on the neglect of chronic disease have been appearing for many years. See, for instance, "Health Policy and Chronic Illness," Society 25 (November/December 1987): 33-39.

1. I have chosen a parsimonious citation strategy for this book. The purpose of the strategy is to inform expert readers without cluttering the text with numbers. Thus, I cite quotations or extensive paraphrases from primary sources only when I have not previously cited them in one of the articles I published during the years I explored the information and ideas that I synthesize in this book. When I have previously cited a source, the endnote refers readers to the published article in which that source was cited. Similarly, I do not cite secondary sources for information that is generally accepted by people who do research on health policy and its history. But I cite secondary sources that offer new insights, or are controversial, or are, at this writing, unpublished.

The quotation in this paragraph is from "The Need of Hospital Provision for Chronic Patients," Report of the Public Health, Hospital and Budget Committee of the New York Academy of Medicine to the Commissioner of Health of New York City (New York Academy of Medicine Archives, CPH CD 191430), April 1914.

2. Vital Statistics in the United States, 1940-1960 (Washington, D.C.: Department of Health, Education and Welfare, National Center for Health Statistics, 1968), p. 79.

3. Ibid.

4. Ibid.

5. Anne-Emanuelle Birne and Daniel M. Fox, "Chronic Disease Morbidity and Mortality in the United States since 1900," unpublished paper, 1991. This paper is the source of the data in the following paragraphs, except where other sources are cited. We hope eventually to publish the documentation for this paper.

6. James C. Riley, Sickness, Recovery and Death: A History and Forecast of Ill Health (Iowa City: University of Iowa Press, 1989). For the current controversy about how to interpret morbidity data, see S. Ryan Johansson, "The Health Transition: The Cultural Inflation of Morbidity during the Decline of Mortality," Health Transition Review 1, no. 1 (1991): 39-68; and James C. Riley's reply, "From a High Mortality Regime to a High Morbidity Regime: Is Culture Everything in Sickness," Health Transition Review 2, no. 2 (1992): 71-89.

7. The most convenient of several sources for the data on the National Health Survey in this and the following paragraphs is The National Health Survey, 1935-36: The Magnitude of the Chronic Disease Problem in the United States, preliminary reports, Sickness and Medical Care Series, Bulletin no. 6 (Washington, D.C.: Division of Public Health Methods, National Institutes of Health, U.S. Public Health Service, 1938), pp. 1-19.

8. Quotations cited in Daniel M. Fox, "Financing Health Services for the Chronically Ill and Disabled: A History of Political Accommodation," Milbank Quarterly 67, supp. 2, part 2 (1989): 257-89.

9. See Ronald W. Wilson and Thomas F. Drury, "Interpreting Trends in Illness and Disability: Health Statistics and Health Status," Annual Review of Public Health 5 (1984): 83-106. See also Dorothy P. Rice and Mitchell P. LaPlante, "Chronic Illness, Disability and Increasing Longevity," in The Economics and Ethics of Long-Term Care and Disability, ed. Sean Sullivan and Marion Ein Lewin (Washington, D.C.: American Enterprise Institute, 1988). An important unpublished study is Richard W. Osborn, "A Time Series Analysis of Population Morbidity and Disability," Department of Preventive Medicine and Biostatistics, Faculty of Medicine, University of Toronto, 1991. Osborn finds that "in direct opposition to the popular model we find there to be an increasing prevalence of chronic conditions over the time period [1969-81]" (p. 18).

10. See Daniel M. Fox, Health Policies, Health Politics: The Experience of Britain and America, 1911-1965 (Princeton, N.J.: Princeton University Press, 1986), and "Medical Institutions and the State," in Encyclopedia of the History of Medicine, ed. W. Bynum and R. Porter (London: Routledge, 1993); Kenneth Ludmerer, Learning to Health (New York: Basic Books, 1985); Charles Rosenberg, The Care of Strangers: The Rise of American Medicine (New York: Basic Books, 1985); Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982); and Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (New York: Basic Books, 1989).

11. There is an extensive literature health reform in this period. See especially the works by Stevens, Starr, and Fox cited in the preceding note. For what follows on early health insurance, the literature is sparse. See, however, D. M. Fox, David Rosner, and R. A. Stevens, "Between Public and Private: A Haft Century of Blue Cross and Blue Shield in New York: Introduction," Journal of Health Politics, Policy and Law 16 (Winter 1991): 643-50, and the other papers assembled in the same issue of this journal.

12. The source for Parran's astonishing quote is the transcript of a radio broadcast he made on the Columbia network, July 19, 1938, in Box 169, NIH Government File, Record Group 443, National Archives of the United States.

13. The quotes in the next several paragraphs are cited in Fox, "Financing Health Services."

14. For citations to most of the quotations and paraphrases in this section, see D. M. Fox, "Health Policy and Changing Epidemiology in the United States: Chronic Disease in the Twentieth Century," in Unnatural Causes: The Three Leading Killer Diseases in America, ed. R. Maulitz (New Brunswick, N.J.: Rutgers University Press, 1989), and "Financing Health Services." The story I tell in this section is, however, based mainly on extensive reading in archival sources. For a list of these sources, see the Note on Methods and Sources at the end of this book.

15. A. E. Cohn, Memorandum for a meeting with Robert Maynard Hutchins, May 1935, Cohn Papers, Box 18 (7), Rockefeller Archives Center, Tarrytown, N.Y.

16. Ernst P. Boas, Treatment of the Patient Past Fifty (Chicago: Year Book Publishers, 1941), p. 5.

17. For citations see Daniel M. Fox, "The Politics of the NIH Extramural Program, 1937-1950," Journal of the History of Medicine and Allied Sciences 42 (October 1987): 447-66.

18. As I described in "The Politics of the NIH Extramural Program," the participants in these events subsequently remembered them as less controversial than the evidence in manuscript sources reveals, and as more focused on science than on chronic disease. A telling confirmation of my point, however, is in the "closing comment" in James A. Shannon's memoir of the 1950s, "The National Institutes of Health: Some Critical Years, 1955-57," Science 237 (August 21, 1987): 865-68. Shannon takes for granted the centrality of chronic disease to NIH policy: "Within the complexities of the many chronic diseases of concern to NIH . . . the immediate objectives were to increase the order of magnitude of the [research] effort, provide a broader base of understanding of the biological systems involved, and, with an increasing knowledge of the natural history of disease, approach its [chronic disease's] solution in an opportunistic fashion."

19. Primary sources about lobbying on behalf of NIH are in the Mary Switzer Papers, Schlesinger Library, Radcliffe College. For mental health policy in these years, see Gerald Grob, From Asylum to Community: Mental Health Policy in Modern America (Princeton, N.J.: Princeton University Press, 1991).

20. Daniel M. Fox, "Sharing Governmental Authority: Blue Cross and Hospital Planning in New York City," Journal of Health Politics, Policy and Law 16 (Winter 1991): 719-46.

21. For documentation on support for these priorities, see Fox, Health Policies, Health Politics, chaps. 7 and 9.

22. David Seegal and Arthur R. Wertheim, "Prospects for the Prevention of Chronic Disease," paper presented at the conference on Preventive Aspects of Chronic Disease, sponsored by the Commission on Chronic Illness, the National Health Council, and the U.S. Public Health Service, Chicago, March 12-14, 1951.

23. Daniel M. Fox and Marcia Meldrum, "Cortisone 1949-1950: History and the Politics of Medical Progress," paper presented at the annual meeting of the American Association for the History of Medicine, Baltimore, May 1990. In conversation, Kenneth Ludmerer noted that the Mayo Clinic, unlike Merck, surrendered its patient claims to Cortisone in the public interest. Physicians' ethical views of their public obligation changed markedly, he continued, between 1947 and the events I discuss in chapter 4.

1. For citations not otherwise noted, see Daniel M. Fox, "Financing Health Services for the Chronically Ill and Disabled: A History of Political Accommodation," Milbank Quarterly 67, supp. 2, part 2 (1989): 257-89, and "Health Policy and Changing Epidemiology in the United States: Chronic Disease in the Twentieth Century," in Unnatural Causes: The Three Leading Killer Diseases in America, ed. R. Maulitz (New Brunswick, N.J.: Rut-gers University Press, 1989). For a general history of these issues, see Fox, Health Policies, Health Politics: The Experience of Britain and America, 1911-1965 (Princeton, N.J.: Princeton University Press, 1986); and Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (New York: Basic Books, 1989).

2. Kenneth Ludmerer, "American Medical Education in the Twentieth Century: A Prospectus," unpublished manuscript, 1992, p. 9.

3. For citations on rehabilitation and disability in this period, see Edward Berkowitz and Daniel M. Fox, "The Politics of Social Security Expansion: Social Security Disability Insurance, 1935-1986," Journal of Policy History 14 (Summer 1989): 239-60.

4. The Multiple Screening Idea (New York: Health Information Foundation, n.d. but probably 1952), copy in the Douglas Colman Papers, Empire Blue Cross/Blue Shield Archives.

5. Eli Ginzberg, A Pattern for Hospital Care: Final Report of the New York State Hospital Study (New York: Columbia University Press, 1949), p. 180.

6. The sources quoted in this and the next two paragraphs are in Leona Baumgartner Papers, Organization File to 1962, file labeled "Interdepartmental Health Council," Harvard Medical Archives, Countway Library, Boston.

7. Talcott Parsons, The Social System (New York: Free Press, 1951), chap. 10. This reading of Parsons places him in the context of his time as a social scientist. It contradicts the more frequent reading of Parsons as a normative lawgiver. This is not the place to defend at any length the benefits of using the methods of intellectual history to analyze the social science of an earlier generation. But such a defense would note that Parsons was indebted to Henry Sigerist's classic paper of 1929, "The Special Position of the Sick" (in Henry E. Sigerist on the Sociology of Medicine, ed. M. I. Roemer [New York: MD Publications, 1960]). Sigerist, writing in an earlier generation than Parsons, emphasized that the "goal of medical intervention is the restoration of function." Parsons, observing several decades of popular assimilation of optimistic ideas about medical progress, replaced the concept of function with the much more demanding task of "getting well."

8. Parsons, The Social System, p. 431, n. 7.

9. See pertinent papers in Irving K. Zola, Socio-Medical Inquiries: Reflections, Recollections and Reconsiderations (Philadelphia: Temple University Press, 1983).

10. W. C. Amtz to Elmer B. Staats, February 5, 1960, Record Group 51, Bureau of the Budget Series 51.3a, Box 19, National Archives of the United States.

11. David Bell to John F. Kennedy, March 10, 1961, Record Group 51, Bureau of the Budget Series 61.1a, R5-2/2, Box 45, National Archives.

12. Internal White House correspondence reveals that opposition to crash programs remained strong but ineffective. William Cannon, an official in the Bureau of the Budget, insisted that the activities on behalf of diffusing technology for these diseases "would accomplish little and would actively harm our efforts to keep the NIH budget under executive branch control." Cannon believed that the "problems posed by cancer, heart disease and stroke are primarily research problems" for which NIH already had enough money (William Cannon to Myer Feldman, September 30 and July 26, 1963, Record Group 51, Bureau of the Budget Series 69.1, Box 82, National Archives). For an analogous view, expressed on behalf of community mental health programs as a solution to the problems of the severely mentally ill, see Gerald Grob, From Asylum to Community: Mental Health Policy in Modern America (Princeton, N.J.: Princeton University Press, 1991).

13. Again, this account is based on manuscript sources in the National Archives, which I cite in telling the larger story in "International Perspectives," in Human Resources for Health: Defining the Future, ed. C. M. Evarts et al. (Washington, D.C.: Association of Academic Health Centers, 1992).

14. D. M. Fox, "Sharing Governmental Authority: Blue Cross and Hospital Planning in New York City," Journal of Health Politics, Policy and Law 16 (Winter 1991): 719-46.

15. The evaluators were Arthur D. Little, Inc., and a nonprofit firm called the Organization for Social and Technical Innovation. I was a principal in the latter and principal investigator of the sole-source contract to evaluate CHP. Everything reported in this paragraph is personal observation.

16. Fox, "Financing Health Services." I am indebted to James Maxwell's still unpublished history of Blue Cross in New York for some of what follows. Much of what I say about the Blues and the commercials is a result of documents in the archives at Empire Blue Cross and Blue Shield, notably the papers of Louis Pink and Douglas Colman.

17. Chester J. Pack, Jr., and Elmo Richardson, The Presidency of Dwight D. Eisenhower (Lawrence: University of Kansas Press, 1991), p. 56. See also Gary W. Reichard, Politics as Usual: The Age of Truman and Eisenhower (Arlington Heights, Ill.: Harlan Davidson, 1988), pp. 86-87.

18. Stephen Ambrose, Eisenhower: The President, vol. 3 (New York: Simon and Schuster, 1984), p. 199.

19. For primary sources on the history of Social Security Disability Insurance, see Berkowitz and Fox, "The Policies of Social Security Expansion."

20. For the literature on Medicare and chronic disease, see Fox, "Financing Health Services." The most recent assessment of this issue is Lawrence R. Jacobs, A Social Interpretation of Institutional Change: Public Opinion and Policy Making in the Enactment of the British National Health Service Act of 1946 and the American Medicare Act of 1965. Ph.D. dissertation, Columbia University, 1990; forthcoming as a book from Cornell University Press.

21. John Francis to William Carey, "Events Leading to the Establishment of the Gottschalk Committee," memorandum, March 18, 1968, Record Group 51, BoB file 60.3a, Box 23, National Archives of the United States.

22. John Francis to Pierre Palmer, August 10, 1967, Record Group 51, BoB file 60.3a, Box 23, National Archives; Richard A. Rettig, "Origins of the Medicare Kidney Disease Entitlement: The Social Security Amendments of 1972," in Biomedical Politics, ed. K. E. Hanna (Washington, D.C.: National Academy Press, 1991), 189-90.

23. Sandra Tannenbaum, "Medicaid and Disability: The Unlikely Entitlement," Milbank Quarterly 67, supp. 2, part 2 (1989): 288-310.

24. The leading explanations of our health financing policy are assessed, rather differently, in Fox, Health Policies, Health Politics; Starr, Social Transformation of American Medicine; and several thoughtful works by Hollingsworth, most recently J. Rogers Hollingsworth, Jerald Hage, and Robert A. Hanneman, State Intervention in Medical Care: Consequences for Britain, France, Sweden, and the United States, 1890-1970 (Ithaca, N.Y.: Cornell University Press, 1990).

25. This section is based mainly on research in the Contemporary Medical History Archives of the Wellcome Institute for the History of Medicine, the British Public Records Office, the archives of the British Geriatric Society, and printed public primary sources in the British Library. I have told the story in more detail in "The Perception of Chronic Illness in Health Policy: Britain and America, 1930s-1960s," in Program, Papers and Abstracts for the Joint Conference of the British Society for the History of Science and the History of Science Society (Manchester: BHSS and HSS, 1988).

26. Report of the Ministry of Health for the Year Ended 1945 Including the Report of the Chief Medical Officer of Health on the State of the Public Health for the Year Ended 1945 (London: Her Majesty's Stationery Office, 1946), pp. 77-78, 81, 13.

27. Interview, Bath, United Kingdom, July 1988.

28. In particular see the papers of Sir Thomas Lewis and Sir Edward Mellanby, both in the Contemporary Medical Archives Center, Wellcome Library and Institute for the History of Medicine, London.

29. Rudolf Klein, The Politics of the National Health Service, 2nd ed. (London: Longmans, 1989). I have a special debt to Professor Klein as a result of many conversations with him about health policy in the United States and the United Kingdom.

30. A notable publication that discusses the "young chronic sick" is Separation of Younger from Older Patients in Hospitals (London: Her Majesty's Stationery Office, 1975).

31. King's Fund Commission on the Future of London's Acute Health Services, London Health Ca re 2010: Changing the Future of Services in the Capital (London: King Edward's Hospital Fund for London, 1992). An official commission soon recommended that the government accept most of the recommendations by the King's Fund Commission. See Sir Bernard Tominson et al., Report of the Inquiry into London's Health Service, Medical Education and Research (London: Her Majesty's Stationery Office, 1992).

32. I am grateful to Dr. Michael Ashley-Miller, secretary of the Nuffield Provincial Hospitals Trust, for conversations that bear on this paragraph.

1. Advocates of prevention policy frequently get upset when they are confronted with evidence that prevention does not always save money or that rational political actors must consider when and in whose budget savings occur. For this debate see, for example, Louise Russell, Educated Guesses (Berkeley and New York: University of California Press and Milbank Memorial Fund, forthcoming).

2. Theodore R. Marmor, Jerry L. Mashaw, and Philip Harvey, America's Misunderstood Welfare State (New York: Basic Books, 1991).

3. Robert Griffith, "Dwight D. Eisenhower and the Corporate Commonwealth," American Historical Review 87 (February 1982): 87-122.

4. Walter Dean Burnham, "Into the 1980s with Ronald Reagan," in The Current Crisis in American Politics (New York: Oxford University Press, 1982, pp. 273-76), takes a slightly different view of the political history of centralization. He argues that a "momentous transition . . . toward [a] much more active and intrusive federal role in the maintenance of . . . social harmony" took place after 1965. I believe that, for ideological purposes, it began considerably earlier. On Wilbur Cohen, see the forthcoming biography by Edward Berkowitz.

5. On the history of conservative political thought, see George N. Nash, The Conservative Intellectual Movement in America (New York: Basic Books, 1976); and Davis W. Reinhard, The Republican Right since 1945 (Lexington: University Press of Kentucky, 1983). Burnham ("Into the 1980s with Ronald Reagan," p. 280) writes of the "continuing vitality of the American liberal-capitalist political tradition, and the enduring hostility to the state, to organized labor, to the poor that arises from this kind of uncontested cultural hegemony." An important review article on the history of conservative politics is Michael Kazin, "The Grass-Roots Right: New Histories of U.S. Conservatism in the Twentieth Century," American Historical Review 97 (February 1992): 136-55.

6. D. M. Fox, Economists and Health Care (New York: Prodist, 1979), and "Health Policy and the Politics of Research in the United States," Journal of Health Politics, Policy and Law 15 (Fall 1990): 481-99.

7. John C. Burnham, "American Medicine's Golden Age: What Happened to It?" Science 215 (March 1982): 1475-77.

8. See Fox, Health Policies, Health Politics, chaps. 5 and 7.

9. Similarly, in September 1992, the American College of Physicians, the largest organization of specialists, announced a comprehensive plan for health policy reform, including cost controls, that was immediately dismissed by the White House.

10. For details about alleged profit seeking among physicians, see Bradford H. Gray, The Profit Motive and Patient Care: The Changing Accountability of Doctors and Hospitals (Cambridge, Mass.: Harvard University Press, 1991); and Walt Bogdanich, The Great White Lie: How America's Hospitals Betray Our Trust and Endanger Our Lives (New York: Simon and Schuster, 1991).

11. D. M. Fox and D. C. Schaffer, "Health Policy and ERISA: Interest Groups and Semi-preemption," Journal of Health Politics, Policy and Law 14 (Summer 1989): 239-60.

12. D. M. Fox and D. C. Schaffer, "Tax Policy as Social Policy: Cafeteria Plans, 1987-1985," Journal of Health Politics, Policy and Law 12 (Winter 1987): 447-66.

13. For the earlier history of physician self-control of conflicts of interest, see Katherine Ann Durso, "Profit Status in the Early History of Health Maintenance Organizations," Ph.D. diss., Yale University, 1992.

14. K. Ludmerer, "American Medical Education in the Twentieth Century: A Prospectus," unpublished manuscript, 1992, p. 16.

15. Stephen M. Shortell, "Revisiting the Garden: Medicine and Management in the 1990s," Frontiers of Health Services Management 7 (Fall 1990): 5.

16. Bogdanich, The Great White Lie, p. 136.

17. Jean M. Mitchell and Elton Scott, "New Evidence of the Prevalence and Scope of Physician Joint Ventures," Journal of the American Medical Association 268 (July 1, 1992): 80-84.

18. Daniel M. Fox, "Medical Institutions and the State," in Encyclopedia of the History of Medicine, ed. W. Bynum and R. Porter (London: Routledge, 1993).

19. Arnold S. Relman, "Self-Referral—What's at Stake?" New England Journal of Medicine 327 (November 19, 1992): 1522-24. Relman has written many other articles on this subject.

20. Quoted in Bogdanich, The Great White Lie, p. 104, from Internist, January 1987, p. 26. Similarly, the General Accounting Office reported in 1992 that "unscrupulous health care providers, including practitioners and medical equipment suppliers, . . . cheat health insurance companies and programs out of billions of dollars annually." See U.S. General Accounting Office, Health Insurance: Vulnerable Payers Lose Billions to Fraud and Abuse, Report to the Chairman, Subcommittee on Human Resources and Intergovernmental Relations, Committee on Government Operations, House of Representatives, B-246412 (Washington, D.C.: General Accounting Office, May 7, 1992).

21. Marc Rodwin, Medicine, Money and Morals: Physicians' Conflict of Interest in the United States (New York: Oxford University Press, 1993). Instances in point appear regularly in the medical press. For example, "utilization, charges per patient, and profits are higher when physical therapy and rehabilitation facilities are owned by referring physicians": Jean M. Mitchell and Elton Scott, "Physician Ownership of Physical Therapy Services," Journal of the American Medical Association 268 (October 21, 1992): 2055-59.

22. Robert Petersdorff, quoted in Daniel M. Fox, "Physicians' Antagonism to Lawyers: AIDS as Irritant and Opportunity," in AIDS and the Law, ed. Scott Burris (New Haven, Conn.: Yale University Press, 1987; rev. ed., 1992).

23. I witnessed this event (the lobbyist complaining to the committee about physicians' behavior toward legislators) by accident, because I was attending the executive committee's meeting to address another issue.

24. An extensive correspondence on this subject—including letters by Rockefeller, Gregg, and distinguished scientists—took place between April and August 1948 and is filed in the papers of the Rockefeller Foundation, R62 200 412 2779, Rockefeller Archives Center, Tarrytown, N.Y.

25. James F. Fries, "The Compression of Morbidity: Near or Far?" Milbank Quarterly 67 (Spring 1989): 208-31.

26. Office of Technology Assessment, U.S. Congress, Impact of Randomized Clinical Trials on Health Policy and Medical Practice: Background Paper, OTA-BP-H-22 (Washington, D.C.: U.S. Government Printing Office, 1983).

27. See Anne-Emanuelle Birne and Daniel M. Fox, "Chronic Disease Morbidity and Mortality in the United States since 1900," unpublished paper, 1991.

28. World Health Organization, Preamble, Constitution of the WHO (Geneva: World Health Organization, 1946).

29. This paragraph and those that follow on this subject owe a great deal to Deborah A. Stone, "At Risk in the Welfare State," Social Research 56 (Autumn 1989): 591-633.

30. Similar implications of the increasing prevalence of disability are discussed in a provocative article by Gareth H. Williams, "Disablement and the Ideological Crisis in Health Care," Social Science and Medicine 32, no. 4 (1991): 517-24.

31. Daniel M. Fox, "AIDS and the American Health Polity: The History and Prospects of a Crisis of Authority," in AIDS: The Burdens of History, ed. E. Fee and D. M. Fox (Berkeley: University of California Press, 1988), and "Chronic Disease and Disadvantage: The New Politics of HIV Infection," Journal of Health Politics, Policy and Law 16 (Summer 1990): 341-55.

32. Elizabeth Fee and Daniel M. Fox, "The Contemporary Historiography of AIDS," Journal of Social History 23 (Winter 1989): 303-14; D. M. Fox, R. Klein, and P. Day, "The Power of Professionalism: Policies for AIDS in Britain, Sweden and the United States," Daedalus 118 (Spring 1989): 93-112.

33. David J. Rothman and Harold Edgar, "Scientific Rigor and Medical Realities: Placebo Trials in Cancer and AIDS Research," in AIDS: The Making of a Chronic Disease, ed. E. Fee and D. M. Fox (Berkeley: University of California Press, 1992).

34. Daniel M. Fox, "Health Policy and the New Disability Policy: The Potential for Convergence," in Social Insurance for the Nineties, Proceedings of the Third Conference of the National Academy of Social Insurance (Washington, D.C.: National Academy of Social Insurance, 1992).

35. Daniel M. Fox, ed., "The Baby Jane Doe Papers," Journal of Health Politics, Policy and Law 11 (Summer 1986): entire issue. I was a participant in some of the politics of the Baby Jane Doe case as a senior official of the Health Sciences Center of the State University of New York at Stony Brook. David J. Rothman discusses the convergence of disability and health policy around neonatal issues in Strangers at the Bedside (New York: Basic Books, 1991), chap. 10.

36. Jane West, ed., The Americans with Disabilities Act: From Policy to Practice (New York: Milbank Memorial Fund, 1991).

37. Jane West, Moving toward the Mainstream: Disability Rights Policy and Politics in the 100th Congress, final report of a 1989-90 Mary E. Switzer Rehabilitation Research Distinguished Fellowship Grant (Washington, D.C.: U.S. Department of Education, 1992)·

1. John W. Kingdon, Congressmen's Voting Decisions, 3rd ed. (Ann Arbor: University of Michigan Press, 1989). Kingdon writes, for example, "The members' own policy attitudes, their own conception of good public policy remained central driving forces in their decisions [p. xi]. . . . Interest groups are important, but mostly when they can claim a constituency connection [p. xiii]. . . . [Legislators] take cues from fellow congressmen . . . and look for consensus in the fields of force that affect them" (p. xiii). See also Carol H. Weiss, ed., Organizations for Policy Analysis: Helping Government Think (Newbury Park, Calif.: Sage, 1992), pp. 13-14: "What actually happens depends on the mix of interests, ideologies and institutional procedures in the public domain and on the political will to make things happen."

2. For attitudes toward hospital governance, see Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (New York: Basic Books, 1989), and "Can the Government Govern? Lessons from the Formation of the Veterans Administration," Journal of Health Politics, Policy and Law 16 (Summer 1991): 281-306.

3. Thomas Ricketts, "The Future of the Small Rural Hospital," unpublished report for the Milbank Memorial Fund, 1992.

4. Mary Stuart, "Redefining Boundaries in the Financing and Care of Diabetes: The Maryland Experience," paper commissioned by the Milbank Memorial Fund, 1992 (under review for publication).

5. Roger A. Rosenblatt, "Specialists or Generalists: On Whom Should We Base the American Health Care System?" Journal of the American Medical Association 267 (March 25, 1992): 1665-66. This editorial commented on the findings reported in the same issue (pp. 1624-30) by Sheldon Greenfield et al., "Variations in Resource Utilization among Medical Specialties and Systems of Care."

6. The quote is from Thomas B. Graboys et al., "Results of a Second-Opinion Trial among Patients Recommended for Coronary Angiography," Journal of the American Medical Association 268 (November 11, 1992): 2537-40.

7. The most dramatic and well publicized of these studies is the meta-analysis of pregnancy and childbirth directed by Ian Chalmers and his colleagues, based in the newly named Cochrane Center at Oxford University. For a list of interventions that cause harm, see Ian Chalmers, Murray Enkin, and D. Keirse, Effective Care in Pregnancy and Childbirth, vol. 2, Appendix 1 (Oxford: Oxford University Press, 1990).

8. Ann Scitovsky, "Medical Care in the Last Twelve Months of Life: The Relation between Age, Functional Status and Medical Care Expenditures," Milbank Quarterly 66 (1988): 656; Sally C. Stearns et al., "Hospital Use during the Last Year of Life: Does Implicit Rationing Occur for the Elderly with Poor Prognosis?" report prepared for the Milbank Memorial Fund, 1992 (under review for publication), 21. For anecdotal data about physician, family, and patient complicity in limiting care for patients with poor prognoses, see Robert Zussman, Intensive Care: Medical Ethics and the Medical Profession (Chicago: University of Chicago Press, 1992). Zussman argues that care for the terminally ill is in fact negotiated rather than rationed.

9. D. M. Fox and D. C. Schaffer, "Health Policy and ERISA: Interest Groups and Semi-preemption," Journal of Health Politics, Policy and Law 14 (Summer 1989): 239-60.

10. Lawrence Jacobs, A Social Interpretation of Institutional Change (ch. 3, n. 20).

11. Stephen L. Percy, Disability, Civil Rights and Public Policy: The Politics of Implementation (Tuscaloosa: University of Alabama Press, 1989), p. 221.

12. A very persuasive argument that these results are possible without massive institutional, and therefore political, change has been made by Patricia M. Danzon, "Hidden Overhead Costs: Is Canada's System Really Less Expensive?" Health Affairs 11 (Spring 1992): 30. Danzon writes: "The . . . common argument that monopoly insurers have lower costs of risk and other functions because of the larger risk pool is inconsistent with the evidence. . . . The survival of both small and large insurers indicates that scale economies from risk pooling are eliminated at fairly small scale or can be achieved through reinsurance."

13. Jack A. Meyer, Sharon Silow-Carroll, and Brian Garrett, Setting New Priorities in Health Care (New York: Milbank Memorial Fund, 1993).

14. In an important article, two Canadian economists make this argument (that health care expenditures are less advantageous to the economy than other expenditures are) and add that spending to expand the health sector may itself have negative effects on both the creation of wealth and the health of populations. See Robert G. Evans and Gregory L. Stoddart, "Producing Health, Consuming Health Care," Social Science and Medicine 31, no. 12 (1990): 1347-63. A century ago, there seemed to be evidence that spending for health services was good for the general economy. The campaign to eradicate hookworm in the South surely added to the productivity of the work force. The contemporary evidence is less compelling. Disability rights advocates contend that services that permit people to work prevent individual and social costs of dependency. On the other hand, as the population ages, a great deal is spent on services to people who are not in the productive economy.

15. Emily H. Thomas and Arlene H. Nolan, "What Is a Hospital? A Profile of Hospitals in the United States," unpublished report to the Milbank Memorial Fund, May 1992. Their calculation of the cost of staffed but empty beds was disputed by other experts. People who treasure futilitarian arguments (the woodwork effect, described in the text, is another) enjoy arguing that changes in policy will have little or no effect. For a stimulating analysis of the reasons these arguments are persuasive, see Albert O. Hirschman, The Rhetoric of Reaction: Perversity, Futility, Jeopardy (Cambridge, Mass.: Belknap Press of Harvard University Press, 1991).

Futilitarianism aside, people who have managed or regulated hospitals know that their expenditures per bed, occupied or empty, can be reduced by pressure from payers and regulators who act in the interests of payers. Moreover, such reductions can be made—up to a point that has hardly ever been reached in modern America—without any direct effect on the intensity or even the quality of these services.

16. I am grateful for this observation, and many others in point, to David C. Hollister of the Michigan House of Representatives.

17. World Health Organization, International Classification of Impairments, Disabilities and Handicaps, rev. ed. (Geneva: World Health Organization, 1980).

18. Philip H. N. Wood, then at the medical school of the University of Manchester, England, the principal author of the classification, spent considerable time explaining its significance to me in July 1988. Wood and others have published extensively on this subject in the international literature. The significance of the International Classification of Impairment, Disabilities, and Handicaps (ICIDH) has been underrated in the United States because it has become the subject of a technical dispute among statisticians. The dispute has precluded it from being used, as it is in many places abroad, as an instrument of administration that implements a new conception of health policy priorities. Anyone wanting to be informed about the use of the ICIDH in policy making throughout the world should get on the mailing list of the World Health Organization Collaborating Center for the ICIDH, National Council for Public Health, P.O. Box 7100, 2701 AC Zoetermeer, Netherlands. As of September 1992, the center had identified 1,068 articles bearing on the use of the ICIDH for policy in the world medical literature.

19. I am grateful to Charles Fox (no relation), then managing editor of Road and Track, for this information in a conversation in 1986. I made a blunder in my telephone conversation with him, asking him to send me a reprint of the article. "A what?" he replied.

20. Both the evidence and the reasons for not exaggerating it are synthesized in Edward Yelin, Work Disability (New Brunswick, N.J.: Rutgers University Press, 1992).

21. Data showing the relationship between reductions in the supply of acute care services and reductions in total health care costs are assembled in Brian Abel-Smith, "Cost Containment and New Priorities in the European Community," Milbank Quarterly 70, no. 3 (1992): 393-416. See also United States General Accounting Office, Health Care Spending Control.' The Experience of France, Germany and Japan, GAO/HRD-92-9 (Washington, D.C.: General Accounting Office, 1991).

22. For a history of and remedies for the problem of an oversupply of specialists, see Eli Ginzberg, "Physician Supply Policies and Health Reform," Journal of the American Medical Association 268 (December 2, 1992): 3115-18.

23. In 1971, government officials in London demonstrated the role of political will in forming such a coalition when they mobilized support for changing priorities in acute services. I describe and cite sources for the London coalition at the end of chapter 3. A promising nationwide alliance of philanthropists and health care providers in the United States is the National Chronic Care Consortium, based in Bloomington, Minnesota. It remains to be seen, however, whether the large hospitals that comprise most of the institutional members of this consortium are more interested in institutional maintenance or in genuine redistribution of resources.

24. There is some evidence that an emphasis on preventing and managing chronic illness would have beneficial effects. The Centers for Disease Control and Prevention in the U.S. Department of Health and Human Services estimates that "eliminating a single risk factor for each of nine key chronic diseases could reduce mortality from these causes by 47%, from 427 per 100,000 persons to 224 per 100,000." Editorial, "Chronic Disease Prevention and Control Activities—United States, 1989," Morbidity and Mortality Weekly Report 40 (October 18, 1991): 697-700.

25. I am grateful to James C. Robinson for new ideas about uncertainty and how to make better policy to address it. His papers on this subject include "A New Institutional Economics Health Care," 1992.

26. Harry Nelson et al., The States That Could Not Wait: Health Reform in Hawaii, Oregon, Minnesota, Vermont, and Florida (New York: Milbank Memorial Fund, 1993).