J. L. BELL is a Massachusetts writer who specializes in (among other things) the start of the American Revolution in and around Boston. He is particularly interested in the experiences of children in 1765-75. He has published scholarly papers and popular articles for both children and adults. He was consultant for an episode of History Detectives, and contributed to a display at Minute Man National Historic Park.

Follow by Email


Tuesday, January 03, 2012

Government Finance of Health Care, 18th-Century Style

Today Boston 1775 welcomes Dr. Sam Forman as a guest blogger. He is the author of the new book Dr. Joseph Warren: The Boston Tea Party, Bunker Hill, and the Birth of American Liberty. This is only the third full biography of Warren, a central figure in the beginning of the Revolutionary War, and the first in decades. Sam is also an expert in health management, and in this essay looks at that side of Warren’s work.

My new biography of Dr. Joseph Warren is the rousing story of one involved citizen who made a big impact in troubled times. Once famous and broadly admired, he is now barely remembered as the Patriot who sent Paul Revere on that legendary ride, and as the hero of the Battle of Bunker Hill, where he was killed in action.

A sidelight to Warren’s tale is interesting relative to a current controversy. Some conservative Republicans and modern Tea Partyers are calling for the repeal of President Obama’s health care financial reforms. They appear to argue that our Revolutionary-Era leaders never countenanced government involvement in health care finance. Such originalist assertions are Libertarian staples on which calls for reductions and elimination of such programs are based.

The notion that American Founders were not involved in government finance of health care is not borne out by the experience of Boston Patriots. Some, like Joseph Warren, were heavily involved in such programs. Politicians on all sides of the modern controversy do not seem to realize this.

All shades on the political spectrum of Warren’s day judged finance of health care of vulnerable populations as a fitting role for government, even as Whigs opposed taxation without representation within the British Empire. The issue was not whether this was an appropriate role of government, but who should hold the government contract and provide the services.

Dr. Joseph Warren held that Massachusetts province contract to provide health care to needy and elderly residents served by the almshouse and workhouse public institutions from 1769 into 1772. Physician services to people served by these institutions was on a fee-for-service basis to the designated physician, payable one or more times yearly, by a committee of Boston overseers. Designation of the physician and his reimbursement were handled separately from the staffing and administration of the almshouse and workhouse.

Dr. Benjamin Church served prior to Warren. Making his clinical rounds on October 20th at the workhouse at the outset of the 1768 British army occupation of Boston, Dr. Church was refused entry at point of bayonet. As a large crowd gathered, only the intercession of Sheriff Stephen Greanleaf gained Church access to his patient and avoided a riot.

This episode and Church’s clinical services to the poor doubtless reinforced his cache as a popular Whig, and may have helped to immunize him against suspicions of disloyalty for years.

Joseph Warren succeeded Benjamin Church as the province-designated physician to provide charity care from about May 1769 through April 1772. Appointments are recorded in the minutes of the Governor’s Council, whose originals are at the Massachusetts Archives. Government reimbursement and charity care patient volume for 1770/71 come from surviving Governor’s Council records and a Town of Boston tabulation approved by a committee headed by John Hancock.

Government reimbursed fee-for-service care for the indigent constituted about 42% of Warren’s practice, based on volume. As a portion of total revenue, estimates range from 64 to 68% for the three years Warren held the post.

Estimates of Government Reimbursed Care by Dr. Joseph Warren to Massachusetts Almshouse Poor as a Portion of His Medical Practice, May 1769 through April 1772

In 1772 Dr. Samuel Danforth, a Loyalist, displaced Joseph Warren. The new appointment may have had political overtones during a period of Whig quiescence and Tory resurgence. Despite his suspect politics, Dr. Danforth later practiced medicine in Boston and went on to become a founder of the Massachusetts Medical Society.

The closest modern equivalent to Massachusetts Province’s provision of health services to the almshouse and workhouse poor, would be a state Medicaid plan or Medicare, if it had a recipient means test.

Dr. Joseph Warren is a favorite Revolutionary figure among modern Republicans, and was idolized by their favorite American president of modern times, Ronald Reagan. The notion that fighting American founder Dr. Warren—very probably an organizer of the historical Boston Tea Party—aggressively pursued governmental finance of health care for the needy, is an important observation for modern observers of all persuasions. The extent of Warren’s provision of government reimbursed care during 1769-1772, and the widespread support that such government involvement enjoyed in Massachusetts by both Patriots and Tories in the Revolutionary era, are noteworthy. They constitute a humanitarian legacy predating the creation of the United States and its Constitution.

Nevertheless, I would not venture to assert that the compelling history of the American Revolutionary era confers originalist clout to any particular modern agenda regarding health care. To do so would be to commit the sin of presentism, the transgression of asserting a modern agenda in the guise of past events.

Thanks, Sam! For more on the care of the poor in colonial Boston, see the published town records The Eighteenth-Century Records of the Boston Overseers of the Poor, edited by Eric Nellis and Ann Decker Cecere and published by the Colonial Society of Massachusetts. Visit Sam’s website for more on Joseph Warren and his compatriots, with weekly updates of primary-source documents.

Sam will speak on Dr. Warren, the early Revolutionary era, and his new biography at the Brookline Booksmith tonight at 7:00 P.M.; at Newtonville Books on Wednesday, 11 January, at 7:00 P.M.; and at Old South Meeting House on Thursday, 19 January, at noon (admission $6, free to Old South members).


Timoteo said...

Seems he has forgot about Medicare and Medicaid...two programs from the government to help the elderly and the poor. Obamacare is about taking control over the entire medical establishment. There is no comparison upon Warren's work and that of the 21st century.

"To do so would be to commit the sin of presentism, the transgression of asserting a modern agenda in the guise of past events."

Seems like Mr. Forman is guilty of his own charge.

This is academic malpractice at its best or liberal propaganda at its worst...


EJWitek said...

Dr Forman's assertion that Dr Benjamin Church's (Dr Warren's colleague and rival) "clinical services to the poor may have helped to immunize him from suspicions of diloyalty for years" is just not borne out by the historical record and I would assert that although Dr Church's efforts at the eradication of smallpox and service to the poor may have increased the respect with which he was held by the Whigs and the people of the town of Boston, it had nothing to do with any suspicions of disloyalty on Dr Church's part.
Indeed, except for one instance in 1772 when Gov Hutchinson mistakenly, I believe, thought that Dr Church was writing for the Government, Dr Church was held to be one of the staunchest of Whigs and his commitment to their cause was hardly under any suspicion or doubt. His election to numerous important committees and as a delegate to the Provincial Congresses as one of the top vote getters certainly would argue otherwise. Had there been any hints of disloyalty, then the shock with which the news of Dr Church's ciphered letter was greeted would certainly have not occurred. Indeed, it was precisely because Dr Church's commitment to the cause was thought to be so great that an over-reaction occurred.
It was only after Dr Church's "treachery" was discovered, that suspicions were retroactively attached to various actions. There is no historical evidence to indicate that Dr Church was playing a double game for years.
Whatever the true circumstances surrounding Dr Church's loyalties are, his medical services to the poor of Boston have nothing to do with them.

J. L. Bell said...

I rather doubt, Timoteo, that Sam Forman has "forgot about Medicare and Medicaid," given that he's a professional in that field.

The Tea Party folks who demanded that the federal government keep out of their Medicare in 2010 did seem to forget the nature of those programs. As did conservative lawmakers who claimed that America's Founders would object to the federal government being involved in health care yet ran on a platform of protecting those programs (until, that is, they could implement Rep. Paul Ryan's privatization plan).

Your statement "Obamacare is about taking control over the entire medical establishment" is so ill-informed that it leaves you with no credibility at all. The health-insurance reform law that came out of the Congress was designed to preserve, and even protect, the market of for-profit private insurance companies. It didn't even allow a public option to provide competition. That scheme was initially designed by the Heritage Foundation and endorsed in the past by Mitt Romney and Newt Gingrich, two of the major contenders for this year's Republican presidential nomination.

Why would the American right wing turn against their own plan and call it a government takeover only when President Obama espoused it? I think such expressions of worry are a mask and excuse for a deeper anxiety about this President, one that most American conservatives can't express publicly or even to themselves. The more such lies people like you tell, Timoteo, the more the truth becomes apparent.

Timoteo said...

Should I imply that if you don't vote for Mitt Romney for President that you are a religious bigot who hates Mormons?

After all, they are both for "helath care reform" Obama just copied Romney's plan....why go with a copy when you can have the original?

Well anyway Mr. Bell, thanks for the guest blog, now I know not to buy his book. Perhaps I will write a few bad reviews of it on Amazon...isn't that what you liberals do: comment negatively on things that go against your political philosophy..regardless if you have read the author's book or not?

Happy New Year.


J. L. Bell said...

Timoteo continues to embarrass himself and bring disrepute on the political positions he tries to support.

Unable to support his claims in the face of facts, unable to recognize the irrationality of those statements, and unable to admit the deeper fears that drive him, Timoteo resorts to lashing out with feeble insults.

Timoteo threatens posting negative reviews of a book he hasn't read because the author has offended his delicate political sensibilities. He tries to justify that in the close confines of his mind by claiming that "liberals" do that. Clearly he's once again projecting his own impulses onto others, trying to rationalize desires based on his fears and resentments. But it's not fooling anyone, even (deep down) himself.

J. L. Bell said...

Here's a challenge for anyone. As I stated above, and Timoteo acknowledged in his ranting way, the health-insurance reform package enacted under President Obama is very similar to the one enacted in Massachusetts under Gov. Mitt Romney. 

I've put forward a hypothesis that calling such a plan a "taking control of the entire medical establishment" and similar things ("socialized medicine," "death panels," &c.) is so inaccurate and so ignorant of the spectrum of health-care policy proposals that it can't be a product of rational thought, but rather reflects deeper fears that the critic is unable to acknowledge. 

But there's a simple way to refute that hypothesis by showing that significant figures in the Republican Party used such rhetoric before Barack Obama became a prominent proponent of that approach. 

So I invite anyone to find three examples of significant figures in the Republican Party calling the Romney program something like a "complete takeover of the health care system" before Barack Obama won the 2008 Iowa caucus. Those three figures can even be Romney's opponents in the 2008 race. But their criticisms can't simply be "Mitt went too far," or "My plan is better." It has to be at the same level of accusation that Republicans have used about the same program after it became associated with Obama.

If people can't find even three examples of Republicans criticizing the program that harshly before Obama came on the scene, then that's more evidence that it's not the plan that critics really fear.

Charles Bahne said...

Allow the cynic in me to fan the political flames in a very different direction:

My interpretation of this is that neither Dr. Warren nor Dr. Church were disinterested observers. They were, in the modern parlance, government contractors. Dr. Warren may have "aggressively pursued governmental finance of health care for the needy"; but in fact he stood to gain personally from the government's decision to finance that health care.

The statistics presented here show that, for three years in a row, Dr. Warren earned about 2/3 of his income from that government contract. Not only that, but his government work paid very handsomely. In 1770-71, he earned £213/16 for 730 government-paid visits, or about 5.86 shillings per visit; and he got £119/11 for 1003 privately-paid visits, or 2.38 shillings per visit.

In other words, on a per-visit basis the government was paying Dr. Warren almost 2.5 times what he earned from his private patients.

Personally, I'm all for government support of health care in the modern world; but this example appears to show that some things never change. Howie Carr, whom I rarely agree with, would have called Dr. Warren a hack.

J. L. Bell said...

It's possible that Warren's public patients were sicker than his private ones because they were poor and had gone without health care for a while before needing government help. But I doubt the resources are solid enough for us to know.

Another of Warren's business activities was clearing up the bankrupt Nathaniel Wheelwright estate, a job he was given by Thomas Hutchinson in his role as a probate judge. That job meant Warren was at odds with his political colleague William Molineux, agent for Wheelwright's former partner and biggest creditor, Charles Ward Apthorp. It's unclear why Warren took that job, or what Hutchinson's motives were.

Apthorp began to suspect Molineux was embezzling from him. Soon after Apthorp raised that question, Molineux died in October 1774 under suspicious circumstances. Warren visited him shortly before he died and left some medicine. Friends of the royal government hinted that Warren had supplied laudanum which Molineux used to commit suicide. Sons of Liberty suggested that British army officers had killed Molineux. (Conspiracy theories are also nothing new.)

Anonymous said...

I will skip the political fight here but will say this: Dr. Warren simply was not espousing the same type of health care plan as contained in thelegislation signed by Presient Obama.

And I have read most of Mr. Forman's book.

I applaud him for his obvious enthusiasm about the subject but his book leaves a great deal to be desired. It is not truly a "biography" but is more akin to a loosely-organized set of notes he compiled on Warren. It is arrange topically, not chronologically, which makes for a great deal of choppy reading, to say the least. And at points he digresses and starts to speak in the first person- an uncommonly annoying thing to me, anyway. He talks about taking a trip out to Central Mass to an apple farm, for instance, in order to get a better sense of the Warren apple orchards.

It still is worth buying, however, if for no other reason than there has not been a biography written of this truly great American in over 50 years.

That, and the fact that the average American does not even know who Dr. Warren was, ought to be the focus of our collective attention and ire, far more so than the narrow issue of whether he was actually espousing universal healthcare as we now conceive of the policy.

J. L. Bell said...

I agree that medicine and the delivery of medical care were both very different in Warren's day. Looking for detailed guidance from a generation that hadn't learned to wash their hands before surgery never seemed wise.

That said, one of the points of dispute in today's debate is whether citizens enjoy a right to medical care. There's nothing about that in the Constitution, of course. But the fact that colonial and town governments provided such care for their poorest inhabitants suggest an even older precedent.