Increasing Priority of Chronic Degenerative Disease

For more than half a century a growing number of experts had urged that more attention and resources be allocated to chronic degenerative disease. In the 1920s and 1930s a few academic physicians had insisted that chronic disease—then often called "incurable illness"—would become more prevalent as the average length of life increased in the United States. They urged their colleagues to accord higher prestige and priority to long-term and home care, but without much success.^[9]

Chronic disease attracted increasing attention in the 1950s. The privately organized Commission on Chronic Illness issued what were later regarded as landmark studies (1956-1959), and some medical specialists began to shift their emphasis from infectious to chronic disease. Among the first to do so were specialists in tuberculosis, who broadened their emphasis to diseases of the respiratory system after streptomycin was introduced as a cure for tuberculosis in the late 1940s.^[10] The new specialty of rehabilitation medicine gained widespread publicity as a result of its success during and after World War II and the vigorous support throughout the 1950s that it received from the Eisenhower administration and Congress.^[11] By the late 1950s the Hill-Burton Act had been amended to encourage the construction of facilities for long-term care and rehabilitation.

Nevertheless, priority within the health polity continued to be ac-

corded to acute rather than long-term care—either for infectious disease or for acute episodes of chronic illness. There were several reasons for this. Physicians' prestige among both their colleagues and the general public continued to rest on their ability to intervene in crises rather than on their effectiveness as long-term managers of difficult cases. Moreover, most of the money to purchase health services was paid by Blue Cross and commercial insurers on behalf of employed workers and their dependents, whose greatest immediate need was for acute care. Organized labor had little incentive to negotiate for fringe benefits for people too old or too sick to work. Since the inception of group prepayment for medical care in the 1930s, Blue Cross and commercial companies had resisted covering care for chronic illness, most likely because they feared that it would lead to adverse selection of risks and undesirably high premiums. Leading spokesmen for voluntary insurance argued that employee groups, even large groups of employees in the geographic areas covered by "community rated" plans, were too small to carry the large financial risks of chronic disease. Nevertheless, a constituency for long-term care of chronic illness was first created in the 1950s by the campaign for Social Security disability insurance and then in the early 1960s by efforts to create what in 1965 became Medicare.^[12]

In the 1960s debates about national policy focused attention on unmet needs for health services in general and especially on care for the chronically ill. Some advocates of health insurance for the elderly under Social Security, enacted as Medicare in 1965, emphasized the need for long-term as well as acute care. Nevertheless, Medicare insured more comprehensively against the costs of acute episodes of illness than for outpatient, nursing home, or home health care.^[13] Medicaid, however, which had been conceived mainly as a program of acute care for recipients of categorical public assistance, quickly became a major payor for nursing home and home health care for the elderly. By 1967 there was little controversy about the inception of the Regional Medical Program, which dispensed federal grants to diffuse the results of academic research about the major chronic diseases—heart disease, cancer, and stroke.^[14]

Federal leadership in shifting priority to chronic degenerative disease continued during the Nixon administration. In 1970 President Richard M. Nixon declared war on cancer.^[15] Two years later an amendment to the Social Security Act nationalized the cost of treating end-stage renal disease by covering kidney transplants and dialysis under Medicare.