June 30, 2012

Kaiser Permanente: Seeds planted amid rancorous 1930s health care debate

Ig Falk, 20th Century public health hero few people know

Isidore “Ig” Falk was a 20th Century hero, but most Americans have never heard of him. Falk was a major figure in the 1930s to 1980s discussion of how health care should be organized in America. He was the head of research for the Senate Committee for the Costs of Medical Care (CCMC), whose voluminous report was published in 1932.

Falk, educated at Yale with a PhD in Public Health, was largely responsible for writing the committee’s recommendations that called for prepaid group practice and integrated health care in America. The committee said that fee-for-service health care should continue to exist, but that in some fashion, quality health care should be made accessible to everyone, rich, poor, and in-between. The committee majority figured that prevention of illness, like public education, was good for the country, as well as for the common man.

Garfield—A grass roots approach

As Ig Falk pursued these ideals on a national scale, another of my heroes—Sidney R. Garfield—was busy putting these ideas into practice on a grass roots level. Born in humble circumstances, Garfield attended medical school at his parents’ insistence and was out to make a living in California during the Great Depression.

Tom Debley's biography of Sidney Garfield, MD, Kaiser Permanente founding physician

For all the right reasons, Falk spent a good chunk of his life advocating for the principles embodied in the committee recommendations. Alas, due to political circumstances, i.e., charges that he was pushing socialized medicine, and a lack of public understanding and support, Falk didn’t succeed in achieving prepaid, coordinated medical care for all Americans. (He’s still a hero in my book.)

Sidney Garfield took care of industrial workers in the California desert on a fee-for-service basis. He soon realized he couldn’t make it if he waited for the patients to come to him. So he made a deal with the workers’ insurance company to pay him in advance for the workers health care. Voila! Prepaid health care that was affordable and sustainable.

Garfield’s troubles begin

With the help of industrialist Henry J. Kaiser, Garfield enhanced and refined his methods of health care delivery and brought them to the World War II home front, and in 1945 introduced his brand of care to the public. That’s when his troubles really began.

Like Falk, Garfield had to fight. He had to fight to keep himself out of jail and in the business of taking care of people. Not only did they call him a socialist or communist, his opponents said he was violating medical ethics, and he was brought up on charges for running a group practice. Anyone who tried to join Garfield’s medical group was scorned by their peers and warned against ruining their careers by being associated with this renegade doctor.

Fortunately, Garfield did not fail. Amid all the obstacles, Garfield kept it together and with the support of organized labor and physicians in academic medicine, today his legacy lives on in Kaiser Permanente. He’s the fellow who pushed his colleagues to get into computers in the early 1960s. He’s the one who pushed the idea that if you screened patients for signs of early chronic illness, you could slow down or stop the advance of disease.

A great model of health care

Garfield is my hero because he persisted in his mission to keep his modest plan alive. He won myriad battles and left us Kaiser Permanente as one of the U.S. models of health care that works. I’m personally glad because I’m one of the lucky ones who have good, no great, health care.

One period of my life when I wasn’t a member of Kaiser Permanente, I sought a mammogram, a vital preventive screening for women. I picked a radiologist out of a network book and I had the exam. Up to a year later, I was still receiving past due notices that my insurance had not paid the claim.

In contrast, in the past two months, I’ve received several letters and phone calls from Kaiser Permanente reminding me that it’s time for a mammogram. When I went in for the exam at a convenient evening hour, my copayment was waived. Somehow I get the feeling that someone is watching over me. Wow!

Health care reform still a discussion

As I’m sure you know, the people in Washington today are wrangling over health care reform again (read, still). Right now the quest for change seems to be stymied by political special interests. Reminiscent of Falk’s time and renewed conversations in the 1940s and the 1990s, transformative change remains elusive. Perhaps a 1997 discussion of Falk’s challenges by Alan Derickson, PhD, in the American Journal of Public Health can help us reach a solution to benefit all Americans:

“If a chorus of demands from many sources were to drown out overheated ideological claims, public discussion might shift to a fuller consideration of human need and the capability of an affluent society to meet it.”

To learn more about Sidney R. Garfield, MD, you can read: Dr. Sidney R. Garfield: the Visionary Who Turned Sick Care into Health Care. The newly released book illuminates for the first time the details of Garfield’s professional and personal struggles and triumphs.