Social Science & Medicine 138 (2015) 136e143

Contents lists available at ScienceDirect

Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed

Framing choice: The origins and impact of consumer rhetoric in US health care debates Nancy S. Lee Department of Communication, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0503, USA

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 10 June 2015

This paper examines the origins of consumerist discourse in health care from a communication perspective via a historical textual analysis of health writing in popular magazines from 1930 to 1949. The focus is on Consumers Union's Consumer Reports and the American Medical Association's lay health magazine, Hygeia. Findings from Consumer Reports show that the consumer movement of the 1930se40s staunchly advocated for universal health insurance. Whereas consumer rights language nowadays tends towards individual choice and personal responsibility, consumerism in health care during that era articulated ideas about consumer citizenship, framing choice and responsibility in collectivist terms and health care as a social good. This paper also illuminates the limits and weaknesses of a central tenet in consumerismdfreedom of choicedby analyzing stories in Hygeia about the doctorepatient relationship. A textual analysis finds that the AMA's justification in the 1930se40s against socialized medicine, i.e., the freedom to choose a doctor, was in practice highly controlled by the medical profession. Findings show that long before the rhetoric of the “empowered consumer” became popular, some patients exercised some choice even in an era when physicians achieved total professional dominance. But these patients were few and tend to occupy the upper socioeconomic strata of US society. In reality choice was an illusion in a fee-for-service era when most American families could not afford the costs of medical care. © 2015 Elsevier Ltd. All rights reserved.

Keywords: USA Consumer choice Consumerism Health care debates Health insurance Obamacare Affordable Care Act ACA

1. Introduction Liberals and conservatives in the US agree on little these days. But when it comes to health insurance, both the left and the right can agree on one thingdhealth care for all is not a right. This was true throughout the 20th century when the US went its own way with market-based health care while the rest of the developed world (i.e., Western Europe and countries like Canada and Japan) were investing in welfare state policies that entrenched health care as a basic social right. And it continues to be true after health care reform was finally achieved in March 2010 with the Patient Protection and Affordable Care Act, commonly known as the ACA. For the left, the ACA represents a giant leap for US health care reform but falls disappointingly short of universal coverage. For the right, who coined the derisive nickname now also embraced by the left, “Obamacare” is “socialized medicine,” a hoary metaphor still potent to rally conservatives against universal health care as a threat to the American way of life.

E-mail address: [email protected]. http://dx.doi.org/10.1016/j.socscimed.2015.06.007 0277-9536/© 2015 Elsevier Ltd. All rights reserved.

In the country that popularized rights language, why does talk of health care as a universal right not capture the imagination? It is not that rights talk about health care does not exist in the US. Take the state of Vermont, which in 2011 passed a bill that aimed to replace the private insurance exchanges established under the ACA with a single payer system that “would guarantee every Vermonter access to health care as a publicly financed good.” (Stick With Act 48, 2014). Or consider a June 2014 poll by the Pew Research Center that shows substantial support from Americans who identify as “consistently liberal” for a single national government health care program, but no support from their consistently conservative counterparts (Pew Research Center, 2014). Several decades worth of polling results indicate most Americans favor the principle of everyone having access to health care but diverge widely on how to pay for it (Kertschner, 2014). Thus, talk of health care as a universal right exists in the US but continues to be a polarizing and divisive issue that the enactment of Obamacare has not squared away. So if not health care framed as a basic human or social right, an entitlement of citizenship, then what kind of discourse tends to frame the conversation on health care in the US? A case can be made that the language of consumerism has come to the fore in the

N.S. Lee / Social Science & Medicine 138 (2015) 136e143

nation's health care debates. Talk of health care in terms of consumer choice and accompanying rights and responsibilities tends to eclipse talk of health care as a universal right. On the campaign trail President Obama frequently talked about the right of health care for all Americans. In a 2007 speech to Families USA he declared, “The time has come for universal health care in America.” (Obama, 2007; “The Time Has Come for Universal Health Care”). Once in office, however, determined to reform health care, Obama adopted a vocabulary that spoke of affordable options and fairness and consumer protections but distinctly left out overt talk of health care as a right. This paper examines the origins of consumerist discourse in health care from a communication perspective via a historical textual analysis of health writing in popular magazines from 1930 to 1949. The focus is chiefly on two periodicals, Consumers Union's Consumer Reports and the American Medical Association's lay health journal, Hygeia. Whereas consumer rights language nowadays tends towards individual choice and personal responsibility, an analysis of Consumer Reports articles finds consumerist discourse in the 1930se40s articulated ideas about consumer citizenship (Cohen, 2003) that framed choice and responsibility in collectivist terms and health care as an indispensible social good. Through an analysis of stories in Hygeia about the doctorepatient relationship, this study also demonstrates the limits and weaknesses of a central tenet in consumerismdfreedom of choicedunder a fee-for-service system during a time of severe economic crises for the American people. 2. Literature review The reasons why universal health care has long eluded the US are plenty, complex and well researched. Significant scholarship on the history of American health care reform has focused on the impact of political institutions and actors (Hoffman, 2001; Oberlander, 2003; Skocpol, 1997; Starr, 1982; Stevens, 2008), economics and policy (Hacker, 2008; Reinhardt, 2011), social movements (Hoffman, 2002), and the medical profession (Ludmerer, 1996; Rosenberg, 1987; Rothman, 1991; Starr, 1982; Stevens, 1989). Some scholarship considers the communicative dimension mostly from the perspective of understanding mass media's role in the political debates on health reform (Grande et al., 2011; Skocpol, 1997). Several scholars have studied health news in the mass media as a form of political communication (Briggs and Hallin, 2010; Hallin et al., 2013; Lawrence, 2004). A few researchers have focused on the intersection of communication/discourse and consumerism specifically in the context of health care reform (Annas, 1995; Lee, 2007; Tomes, 2001, 2006; West, 2014). The popularity of consumer language in the domain of health and medicine has been on the rise since the 1960se70s (Haug and Lavin, 1983; Lee, 2007; Lupton, 1997; Reeder, 1972; Tomes, 2006). But what precisely is “consumerism” referring to when used in discourses about health and medicine? Critics today are inclined to see health consumerism as an outcrop of the hyper-commercialized nature of the US health care system (Annas, 1995; Mahar, 2006). They are not necessarily mistaken; after successive failures to pass comprehensive national health legislation, the profit-driven nature of American health care took off with the corporatization of medicine in the 1970s (Light, 2011; Starr, 1982) and intensified after the 1980s introduced neoliberal policies that increased market penetration of the health care sector (Waitzkin, 2011). An industry that profits from illness readily adopted consumer rhetoricdlanguage that emphasizes “personal empowerment” and “freedom of choice”das a means to promote the buying and selling of health products and services. Consumer discourse also has been deployed to limit medical

137

services when the payout for medical care hurts profits, as in the case of the health insurance industry. From a theoretical perspective, health consumerism has been posited as a form of Foucauldian biopolitics through which the neoliberal state promotes selfregulating health behaviors as a means to control access to the privileges of citizenship (Briggs and Hallin, 2007). Briggs and Hallin (2007) propose a theory of “biocommunicability” to explain the significance of contemporary health information in the mass media as a discursive site that defines the neoliberal subject as an “actively responsible individual” and teaches citizens how to behave accordingly in the health care market (p. 44). Theorizing health consumerism as a form of governmentality (Dean, 1999) builds upon an expanding international body of critical scholarship that interrogates contemporary practices and values regarding health in advanced capitalist states as new forms of neoliberal power and control (Alexander et al., 2014; Ayo, 2012; Crawford, 2006; Galvin, 2002; Lupton, 2014, 1995). The global trend towards greater privatization in national health systems has increased the appeal of greater consumer participation in health care systems since the 1980s (Bury and Taylor, 2008). In the UK example, a neoliberal model of public policy and provision has gained dominance since the Thatcher era that prioritizes managerialism and consumer-driven efficiencies over genuinely democratic participation by users of health and social services (Beresford, 2002, 2010). The neoliberal version notwithstanding, the contemporary concept of patients as active, self-empowered health consumers evolved out of the 1960se1970s patient rights' revolution in the US (Tomes, 2006; Ruzek, 1978). This movement popularized the idea that individuals were entitled to certain protections and freedom of choice as patienteconsumers navigating an increasingly complex medical health industry. Grassroots rights movements, including consumer protections groups like Ralph Nader's Public Citizen, embraced the idea of the patient as an empowered consumer to wrest more autonomy away from a powerful medical establishment and to secure stronger protections against a predacious health insurance industry. Tomes (2006) observes that before the 1960se70s rights movements, the term “consumer” did not appear in everyday parlance to represent patients but a key exception was during the years between the two world wars (p. 92). A new consumer movement emerged at that time that began to see patients as consumers. This paper shall show how the 1930se40s debate over “socialized medicine” and efforts to pass national health insurance legislation in the US was the first example of the patient defined rhetorically and politically as a consumer by progressive consumer groups like Consumers Union to challenge organized medicine in the policy domain. 3. Methods The present paper is based on a sample of health articles published between January 1930 and December 1949 selected primarily from Consumers Reports and Hygeia. This timeframe was chosen because it represents the height of “second wave” consumer activism (Cohen, 2003; Glickman, 2001; Tomes, 2006). One of the primary purposes of this study was to ascertain whether calling the patient a consumer was commonplace or limited to the consumer movement. For comparative purposes, five other periodicals from this period were included. A total of 507 articles were analyzed, 321 from Consumer Reports, 112 from Hygeia, and 74 from the other periodicals combined. All articles underwent two levels of textual analysis: first, to determine if the content addressed health and medical topics and, second, to search for content that explicitly used the word “consumer” to substitute for or in conjunction with “patient.” The study focused on print media because of the

138

N.S. Lee / Social Science & Medicine 138 (2015) 136e143

accessibility of historical periodicals from university library archives. The magazines were chosen according to circulation categories from the N.W. Ayer & Son's Directory of Newspaper and Periodicals extant from 1930 to 1949 (Table 1). General interest periodicals were included to discover whether health topics were newsworthy enough to appear in current affairs magazines during this period. Women's publications were included since health information is a known staple of women's magazines and women traditionally function as household gatekeepers of health. The AMA's Hygeia was selected because it was one of the few health journals in circulation in the 1930se40s. First published in 1923, the AMA conceived Hygeia as a “family health magazine” to educate everyday Americans on all matters of health (Virtual Newsstand, n.d.). Hygeia reached a circulation of 77,659 paid subscribers in 1936 according to the Ayers Directory, the year Consumer Reports was first published. By 1949 Hygeia attained a circulation estimated in Ayers at around 195,387, somewhat more than Harper's number of 136,984 in that year. But the actual audience reach was much wider as Hygeia was available through newsstands, school donations, public libraries, and its articles were reprinted in trade magazines (Virtual Newsstand, n.d.). Consumer Reports was compared against these other periodicals for its coverage of health topics/news of the day and for patienteconsumer rhetoric. Consumer Reports was selected because of its prominence in the North American media landscape and also in the scholarly literature on consumption and consumer history (Cohen, 2003; Glickman, 2001; Katz, 1977; Silber, 1983; Sorensen, 1941; Stole, 2006; Tomes, 2006). Consumer Reports is arguably the most recognized and read publication of the consumer movement. According to its website, Consumer Reports started in May 1936 with a circulation of 4000-plus subscribers (ConsumerReports.org, n.d.); in 1946 it achieved 100,000. In 1992 the magazine attained 5 million paid subscribers in the US making it one of the widest read publications in print. In 2008 the online version, ConsumerReports.org, reached over 3 million subscribers outstripping other consumer websites (ConsumerReports.org, n.d.). No study until the present one, however, has systematically analyzed and compared the text of Consumer Reports to other periodicals to determine that patienteconsumer rhetoric originated with the consumer movement and its role in the public debate on universal health insurance during the 1930se40s. All non-Consumer Reports articles for this study were found through the Reader's Guide Retrospective, a database that indexes articles published in North American popular periodicals from 1890 to 1982. This database does not index Consumer Reports articles from the 1930s up to 1948. A subject search of the other periodicals using the term “physician” and “health insurance” produced articles on doctorepatient and health reform issues. Articles from Consumer Reports were collected in person by accessing bound copies of archived periodicals at the University of California, San Diego, and University of San Diego libraries. Every issue of Consumer Reports between May 1936 and December 1949 underwent a textual analysis of content to uncover articles addressing health and medicine. This process revealed that health

Table 1 Ayers directory circulation categories 1930 to 1949. General interest Women's Publications Trade, Technical and Class Publications:

Harper's Monthly Magazine, Scribner's, Time Good Housekeeping, Ladies' Home Journal Health, Hygiene and Sanitation: Hygeia Commercial & Industrial: Consumer Reports

has been a staple topic since the magazine's debut: most Consumer Reports issues contain at least one article or editorial on health or medical topics for a total of 321 health-related articles out of 139 issues. 4. Findings 4.1. Consumer Reports: the cost of sickness a consumer's concern The lack of affordable health insurance was an urgent focus for the organized consumer movement. This is reflected in the number of health insurance articles found in Consumers Reports in this study. Between 1936 and 1949, Consumer Reports published 45 articles addressing health insurance in some way (i.e., national health insurance, voluntary hospital plans, medical cooperatives, etc.). In comparison Hygeia published 21 health insurance-related articles; Time published 20; Harper's published three, Good Housekeeping carried two, and the Ladies Home Journal published one. A textual analysis of health insurance information published in Consumer Reports reveals that Consumers Union ardently supported efforts to pass federal health insurance even after the AMA successfully pressured the Roosevelt administration to scuttle health legislation from the Social Security Act of 1935. Three leitmotifs persist throughout Consumer Reports in the 1930s and 1940s: denouncing the AMA's political campaigns against federal efforts to pass universal health insurance; highlighting the unaffordability of medical services for most Americans; and advocating government funded health insurance for all. 4.2. Consumers versus the AMA Through articles in Consumer Reports, Consumers Union frequently spoke truth to the AMA's power over health care and politics. For example, a December 1937 article praises “430 distinguished American physicians” for publicly parting ways with the AMA over its opposition against government-led health reform. These physicians “called for a ‘national public health policy directed toward all groups of the population’ on the principle that ‘the health of the people is the direct concern of the government’” (“Revolt in the A.M.A,” 1937, p. 13). The article continues criticizing the AMA for its “do-nothing policies” that serve only the interests of the AMA: “Intent on maintaining the status quo, these men [of the AMA] have refused to hear the complaints of the 40 per cent of the population who get no medical care at all or of the additional 35 per cent who get inadequate care.” (“Revolt in the A.M.A,” 1937, p. 13). A January 1938 article denounces the AMA's “reactionary wing” for attempting to shut down health cooperatives across the country that provided affordable medical care to low-income families. For example, the AMA informed a health cooperative in St. Louis that its practices were “‘eating at the vitals of the medical profession’” and threatened to take legal action against said cooperative if it persisted in serving low cost care (“The A.M.A.’s Die-Hard Department,” 1938, p. 6). And in an August 1945 article in support of the Wagner-Murray-Dingell Bill for national health insurance: “It may well be asked how doctors or the people of this country can have any confidence in medical organizations [i.e., the AMA] which fight so irresponsibility against progressive medical proposals” (“Wagner-Murray-Dingell-Bill,” 1945, p. 216). 4.3. The cost of illness An October 1939 Consumer Reports article, “Medical Care: Some Facts and Figures on the Way the Present Methods Work, and an Analysis of Why They are Working Badly,” summarizes the

N.S. Lee / Social Science & Medicine 138 (2015) 136e143

problems with health care in the US: (1) That there are widespread, unmet medical needs; (2) that the costs of sickness constitute a crushing burden; (3) that there are defects in the quality of existing medical services; (4) that loss of wages and salariesdthe economic loss due to sicknessdis too much. (“Medical Care,” 1939, p. 17) A September 1939 article articulates again the untenable costs of health care for American families: “We know that 40 million people live on annual family incomes of $800 or less, which just permits them an emergency standard of living and makes it impossible for them to purchase medical care” (“The People's Health,” 1939, p. 17). The article further states that another third of Americans have family incomes that do not exceed $1500 a year and are willing to pay for portions of needed medical care “but finds it extremely difficult to budget the cost of illness” (“The People's Health,” 1939, p. 17). Budgeting for medical care was a challenge even for those above the annual $1500 per year household income level:

139

incomes,’” and consumer interests were inadequately represented (“The ‘3c-a-day’ Plans,” 1939, 17e18). Consumers Union continued to call for universal health insurance throughout the 1940s, arguing, “a health insurance program for the American people must be on a national basis” (“Health Insurance for New Yorkers,” 1944, p. 166) and urging the creation of “a nationwide system of universal, compulsory health insurance providing every citizen with complete and high quality medical care” (“Health Insurance: Consumers vs. AMA”, 1948: p. 280). 4.5. The patient becomes a consumer

Articles like these in Consumer Reports illustrate how medical cost became an increasing burden for ordinary Americans during the inter-world war decades. Scientific advances, the rise of hospitals, and the public's acceptance of doctors as gatekeepers of health contributed to a precipitous upsurge in the price of health care. The situation during the Depression became so onerous even middle class families struggled to budget for the cost of sickness: “Poverty and low income are the chief causes of insufficient medical care, but sickness costs are a serious financial problem for families far above the poverty level” (Medical Care,” 1939, p. 18). Medical costs continued to climb throughout the 1940s; a 1949 Consumer Reports article again states: “It is an agreed-upon fact that medical costs place an increasingly serious strain on the budget of the average American family and that some form of health insurance offers the only available solution” (“Health Insurance Around the Corner?”, 1949: p. 32).

A textual analysis of the periodicals selected for this study found only Consumer Reports called the patient a consumer. Not all articles in the magazine dropped the word patient altogether, such as this condemnation of fee-for-service: “So long as a fee must be paid for a visit to a doctor, the patient will put off going to the doctor” (“Health Insurance for New Yorkers,” 1944, p. 166). And the word consumer could appear interchangeably with patient, as in this heading, “Copywriters as Physicians: CU's advice to the patient (consumer) is: be very careful of what you read” (“Copywriters as Physicians,” 1940, p. 13). Most often consumer substituted for patient in articles about health insurance and in the few articles that touch upon the doctorepatient relationship in the context of Consumers Union's support of group medical care: “The consumer wants the best health care available. He wants it at a price he can afford to pay and he wants to know in advance exactly what that price will be” (“Group Health Associations,” April 1940, p. 32). By describing the patient as a consumer and medicine as a businessd“If medicine as practiced is not a business, why is the Chamber of Commerce so interested in it?” (“The A.M.A. Claims,” June 1940, p. 25)dConsumers Union used consumer rhetoric to expose fee-for-service as an economic system that gave physicians unrestrained power to determine the cost of their services. A comparison of Consumer Reports against the other journals sampled confirms that the patient appears as a consumer in the 1930se40s only in the rhetoric of organized consumerism. A textual analysis of the other journals sampled in this study did not produce any articles that substituted the word consumer for patient, offering further proof that this term was uniquely utilized by the consumer movement in the struggle to create a state-supported rather than purely capitalist health care system.

4.4. Health care a collective cost

4.6. Hygeia: the doctorepatient relationship and freedom of choice, American style

There are, furthermore, millions of families whose income is more than $1500 a year, but to whom medical care presents a serious problem… they are willing to pay for what they get, but, again, find it difficult to budget the cost of illness. (“The People's Health,” 1939, p. 17)

The AMA pressured the Roosevelt administration to drop health care from the Social Security Act of 1935. In the 1940s the AMA continued its aggressive lobbying and fear-mongering media campaigns against socialized medicine, successfully obstructing amendments for national health insurance legislation. But the need remained for some form of collective payment program to help ordinary Americans shoulder the rising costs of health care, especially hospital services. The number of voluntary programs increased nationwide to fill the void. In lieu of a federal health insurance plan, Consumers Union preferred to support non-profit medical cooperatives that provided group care, the prototype of modern managed care. It reluctantly, however, endorsed private hospitalization plans, like the popular “3 Cents a Day” pre-paid plans, because these were often the only insurance available in many communities and at minimum protected consumers against bankrupting hospital costs. A December 1939 Consumer Reports article branded these plans largely inadequate to meet the US public's health needs: “The basic defect is that medical care is excluded… [i]t does not reach enough persons of modest

Between 1930 and 1949 Hygeia published 22 articles that directly discussed the doctorepatient relationship, the most among the magazines sampled here. In contrast, Consumer Reports published only six articles and all focused on the clinical relationship in the context of group care. Good Housekeeping offered up two articles on this topic while none were found in Ladies Home Journal and Time. Out of the 10 Harper's articles retrieved under the search term “physicians,” only one directly examined issues pertaining to the physicianepatient relationship. A textual analysis of Hygeia's doctorepatient articles exposes a dominant theme: the doctorepatient relationship is the soul of American medicine and every effort must be taken to protect it against threats. By threats the physicians writing in Hygeia invariably point to two: socialized medicine and patients themselves. 4.7. The threat of socialized medicine The AMA rhetoric against “state controlled medicine” figures prominently in all the Hygeia articles on health insurance and

140

N.S. Lee / Social Science & Medicine 138 (2015) 136e143

implicitly in many of the doctorepatient articles collected between 1930 and 1949. In a 1934 article about the costs of sickness, Dr. Morris Fishbein, editor of Hygeia, sums up the sanctity of the doctorepatient relationship in American medicine: “… the relationship between doctor and patient is one of the most intimate of human relationships. In some ways it is even more intimate than the relationship a man has with his family” (“Sickness Insurance and Sickness Costs,” 1934, p. 1073e74). He continues, “One of the reasons why American doctors have been opposing any form of state control over medicine is the likelihood that any system of state control will interfere with this personal relationship between the doctor and patient” (“Sickness Insurance and Sickness Costs,” 1934, p. 1074). State interference, according to Fishbein and the AMA, would eliminate a cherished value in American health caredthe freedom of all Americans to choose their own doctor: “Americans always like to choose their own doctors. A good many of the systems of sickness insurance that have been provided in foreign countries do not permit the man to choose the doctor whom he wants” (“Sickness Insurance and Sickness Costs,” 1934, p. 1073). Similar sentiments echo in virtually all the Hygeia articles and editorials on health insurance analyzed for this study. The rhetoric in an April 1935 editorial is typical: “The doctors feel that any form of compulsory sickness insurance is unamerican [sic] and that it is bound to disturb seriously the quality of medical care” (“Plans for Economic Security,” 1935, p. 304). The same rhetoric reverberates in an editorial written a year later: The proponents of most plans for compulsory sickness insurance insist that they provide free choice of physician. This they never do. They provide only free choice of physician from among those who are willing to work under the system … The great menace is the interposition of a third party between doctor and patient as the controlling factor (“Free Choice of Physician,” 1945, p. 255) The rhetoric against socialized medicine continues against Truman's federal health insurance plan introduced in 1945: … compulsory sickness insurance with federal control is both socialized medicine and state medicine … It would make of the doctor a clock watcher and a slave to the system. It is the kind of regimentation that led to totalitarianism in Germany and the downfall of that nation … It is the first step toward a regimentation of utilities, of industries and, eventually, of labor itself. This is the very antithesis of what we call American (“The President's National Health Program,” 1946, p. 15) It persisted after Truman won a second term and was further resolved to pass universal health insurance: “Compulsory insurance through a great government bureaucracy, would destroy individual initiative. Mutual responsibility and confidential relationship between the doctor and the patient would be lost. As a result medical service would deteriorate” (“Voluntary Sickness Insurance,” Aug 1949, p. 555e56).

4.8. The threat of disobedient patients Doctors writing in Hygeia frequently complained about the noncompliant patient. When trouble arose in the medical relationship, “it is far more likely to be due to the unintelligent cooperation of the patient than to the experienced direction of the physician” (Reichert, 1940, p. 109). The same article states: “A doctor learns early that sick persons are often thoughtless and inconsiderate,

sometimes hasty, irritable and uncooperative” (Reichert, 1940, 109). In a 1935 article, a physician praises the majority of his patients for their loyalty but classifies the bad apples into the following types: “suspicious,” “overanxious,” “indifferent,” “ungrateful,” “unstable,” “impatient,” and the “professional invalid” (Whyte, 1935, p. 497e98). Another common complaint was how patients would feign obedience only to surreptitiously seek out second and third opinions. In “A Doctor Looks at His Patients” (Whyte, 1935), a physician writes about his experiences with “selfish” patients. One young woman he examined needed her appendix removed. “She left without much ado” he writes. Shortly after he received a call from a surgeon asking to see if he could administer anesthesia in an appendectomy the following morning: He [the surgeon] was greatly surprised to learn that she [the patient] had just left my office. She had consulted him the day before and had received the same advice I had given, but she was not willing to trust one man's opinion. She may have seen several others, for all we knew. This happens so often that doctors of experience usually learn to “spot” [sic] such patients (Whyte, 1935, p. 497) A cartoon accompanying the article illustrates the “problem” of the sneaky patient: a man tiptoes between three office doors with three different doctors' names, looking furtively over his shoulder to see if he is being watched. A caption reads: “he does not accept the opinion of one doctor: hence he often secretly visits two or more doctors in succession and compares their opinions” (Whyte, 1935, p. 496). Thus, patients who exercised choice vis a vis finding alternative opinions (a mainstay of health care today) were considered ingrates and frowned upon by the medical establishment. 4.9. Did patients pose a real threat? Hygeia essentially acted as the AMA's bullhorn to the masses. Virtually all its articles were written by doctors or reflected their perspective, which was distinctly paternalistic. The patient's voice was nowhere to be found. But articles written by patients did exist for this period, though rare. The ones discovered for this study paint a picture of the patient trapped in a system built to reinforce physician authority over patient autonomy. For example, a 1930 Harper's article, “A Patient Looks at Doctors” (Anonymous, 1930) recounts the author's disastrous experience of a botched operation that pitted her against a medical system that protected physicians even when they were incompetent and left her saddled with debt. A 1931 Scribner's article entitled “Unfit Doctors Must Go” (Halle, 1931) describes a case in which a doctor had administered a drug overdose to a child and its family spent months bouncing from one medical society to the next seeking to strip the physician of his medical license. The medical societies, it turned out, had no power to revoke his license. Adding insult to injury, the family was advised by one of these organizations not to pursue matters further as they would then be exposed to a libel suit (Halle, 1931, p. 515). In a 1936 Scribner's article entitled “A Patient Wants to Know,” the author characterizes the medical profession as tyrannical in its demand for patients to show “a blind, unintelligent faith and obedience that smacks of the Middle Ages” (Yost, 1936, p. 47). Patientsdespecially female patientsdwho spoke up and refused to be treated like children risked having their concerns ignored or downplayed. This, says the author, could endanger their health and even their lives: two of her women friends who were “told to get off their tension” later died of cancer (Yost, 1936, p. 47). She herself consulted different doctors for a physical ailment but was told that her problems were psychological. After three years and several

N.S. Lee / Social Science & Medicine 138 (2015) 136e143

physicians, she finally received serious attention to her conditiondbut only after she lost patience and made it plain to her physicians that there would be no more cooperation on her part if they continued to write her off as a neurotic. These examples illustrate that patients did have serious concerns about the quality and cost of health care available to them, but their voices were largely marginalized. 5. Discussion 5.1. Organized consumerism challenges fee-for-service Results of this study offer evidence that the patient was first called a consumer in the US by the organized consumer movement during the 1930s and 1940s. This linguistic turn is rhetorically significant: by calling patient consumers, the consumer movement reinterpreted the traditionally passive role of the patient (Parsons, 1951) into an entity that could actively question the status quo in health care from a basic position of economics. In this manner Consumers Union helped the consumer movement open the feefor-service system to public debate by defining medicine as a service that must be purchased at a collective cost to consumers, ideally as taxpayers via the state or, failing that, members of medical cooperatives or other group care organizations. This was in keeping with the consumer citizenship ethos of the Depression era that, according to Lisabeth Cohen (2003), became “an acceptable way of promoting the public good, of defending the economic rights and needs of ordinary citizens” (Cohen, 2003, p. 23). Thus, organized consumerism as represented in the pages of Consumer Reports focused on the political economy of medicine at a time when the medical profession regarded the cost of care as strictly an individual matter between doctor and patient, determined by the professional ethics and personal morality of doctors as they assess their remuneration on a patient-by-patient basis. 5.2. The AMA and individualism in US medicine Individualism emerges as an overarching trope in Hygeia. Where health care is discussed in collectivist language in Consumer Reports, the rhetoric in Hygeia firmly exults the individual's freedom to choose a physician as the crowning achievement of American health care. But as this study discovered, the AMA's rhetoric of individual freedom belie the reality: in the golden age of medicine patients did not have much say in their care. Patients lacked what Albert Hirschman (1970) calls “voice” through which to register their frustrations and grievances when the doctorepatient relationship ran afoul. This, however, did not stop some from exercising the economic option Hirschman describes as “exit,” which in the medical context meant leaving one doctor's care for another. From the persistent exhortations in Hygeia to “Be a Good Patient!” (Trewhella, 1943) or to “Give Your Doctor a Break!” (Richardson, 1934), it is possible to infer that physicians found noncompliance enough of an issue to repeatedly admonish patients against making their own health care choices. In fact, historical research on lay health care practices in the US have shown that Americans in the past were more active in taking care of their health needs than previously understood. For example, research into caregiving and “scientific” childrearing practices of the early twentieth century (Abel, 2000), self-care and complementary or alternative medicine (Goldstein, 2004), and doctorepatient relations before the 1920s (Crenner, 2005) challenge the assumption that lay people were more passive about taking control of their health than they are today. This said, evidence from the present study and from the literature at large point to the fact that once Americans accepted doctors

141

as gatekeepers of health, once patients entered into a clinical relationship with their physicians, the freedom to make choices concerning their own health was actively discouraged both at the personal and institutional level. In actual practice, organized medicine's fierce rhetoric in defense of freedom was less to protect the patient's freedom to choose a doctor and more to safeguard the individual physician's freedom to practice medicine as he saw fit. Hence, Eliot Freidson (2001) argues that mid-20th century American medicine was the ideal example of professionalism for the high level of autonomy doctors achieved: “In the most elementary sense, professionalism is a set of institutions which permit the members of an occupation to make a living while controlling their own work” (Freidson, 2001, p. 17). As this paper has shown, for all its rhetoric about the sanctity of voluntary individual initiative as the driver of excellence in American medicine, the AMA was not above organizing its members collectively to secure their political and economic interests as a profession. 5.3. Patient powerdnegligible The articles written by patients included here highlight the power imbalance between physicians and patients in the 1930se40s. The existence of these first-person accounts, together with the persistent griping in Hygeia by doctors about sneaky, double-crossing patients, indicates that some patients struggled against the status quo. It is safe to assume, however, that these patientseauthors represented the exception to the norm. They were most likely white, from an economic stratum that could afford to see doctors, and were educated well enough to write about their bad experiencesdand have their reports published in prestigious magazines with nationwide audiences. Their willingness to speak up, and publicly, about their ordeals in the doctor's office most certainly was not the typical response to medical authoritarianism. As articles in Consumer Reports repeatedly asserted, most Americans during the Depression found it difficult to afford the cost of medical care in the first place. Patients from upper socio-economic classes, however, were affluent enough to create choices for themselves even within a paternalistic medical structure. In contrast, the working class, the indigent, African Americans, and other racial minorities faced endemic discrimination that denied them primary care and basic hospital services (Byrd and Clayton, 2002). 5.4. Consumers lose, AMA wins Organized consumerism during the 1930s and 1940s used consumer rhetoric to counter the AMA's moral defense of individualism in medicine with a social vision of health care as a basic right of citizenship for all Americans. But as history attests, the citizeneconsumer rhetoric of Consumers Union and the second-wave consumer movement failed to topple the mighty influence of the AMA on US policymakers. The citizeneconsumer rhetoric found in Consumers Reports faded right at the moment when American consumer society took off. The AMA's anti-socialized medicine fear mongering, buttressed by its deep economic pockets and the high cultural capital physicians enjoyed, triumphed just as the US entered a post-war period of prosperity and Cold War paranoia. The absence of a national health insurance program felt less urgent during a time when large numbers of working Americans enjoyed decent wages and US corporations began offering ample health insurance plans as a benefit of employment. Medical costs continued to escalate but the majority of workers did not feel the sting as they were covered by their employers' health plans. Seniors, however, the poor, people with disabilities, minorities, and other vulnerable groups were out of luck. Consumers Union

142

N.S. Lee / Social Science & Medicine 138 (2015) 136e143

supported reform efforts in the late 1950s-early 1960s to establish a national health insurance program for the elderly and disadvantaged, but it played a lesser role as new grassroots movements emerged in the struggle to pass Medicare and Medicaid in 1965 (Hoffman, 2002; Tomes, 2006). By the late 1960s a burgeoning patients rights movement in the US adopted consumerist language explicitly to challenge medical paternalism and gain greater self-determination for patients. Seeing themselves as paying customers versus wards of their doctors helped to shift patients,’ and the public's, perceptions and expectations of the physicianepatient relationship (Haug and Lavin, 1983). Neoliberalism's ascent after the 1980s, however, saw the movement's message of personal empowerment and autonomy co-opted by an expanding “medical industrial complex” supported by administrations favoring market-driven approaches to social policy. Outside the US, words like “choice” and “empowerment” have also migrated into national discourses on health policy, reflecting an international trend towards the liberalization and privatization of national health systems. In the UK, for example, the call for greater consumer participation and personal responsibility is frequently associated with state retrenchment in health and social care services versus representing a genuine effort by government organizations to generate greater inclusivity of citizens' needs (Beresford, 2010). 6. Conclusion Consumer rhetoric in US health reform made its first appearance during the New Deal era in fierce support of universal health insurance. Consumer language in the leading consumer magazine, Consumer Reports, articulated a collectivist vision of health care; in contrast, the AMA's individualist rhetoric found in Hygeia enshrined the individual doctorepatient relationship as the soul of American medicine. Results indicate that some patients at this time were behaving as “empowered” patienteconsumers decades before the concept of empowerment emerged in US health care through the patient rights movement of the 1960se70s. These patients were displaying behaviorsde.g., “shopping around” for physicians, collecting second and third opinionsdthat today would be considered common sense under the empowered patienteconsumer model but contradicted the paternalistic norms of American medicine in the mid-20th century. Findings of this study highlight the medical profession's eagerness to control the only exit strategy available to patients when they were dissatisfied with their physicians, i.e., to take their money somewhere else. The conclusion can be drawn that it was not freedom and choice for the patient that organized medicine defended in its rhetoric but rather the professional freedom and power of physicians to dictate the terms of their labor. Organized consumerism framed the lack of universal health insurance as a lack of choice for millions of Americans who could not afford medical care. But it was the AMA's redeployment of the concept of “choice” and their accompanying attack on universal health insurance as the antithesis of American valuesdi.e., freedom of choice and voluntary individual initiativedthat won over public opinion and lawmakers. In large part due to their economic and political clout, the AMA's anti-statist, anti-socialist rhetoric was more persuasive despite the reality that most Americans struggled to budget for the costs of sickness. Parallels can be drawn between the AMA's rhetoric from the 1930se40s and the conservative attacks against successive attempts to expand health insurance and access before the ACA. The difference today is that both sides of the debate now talk in consumer language. Neoliberalist consumer rhetoric has largely eclipsed more democratic forms of consumerist language in health

discourses in the US and has spread globally. Obamacare's supporters speak about consumer affordability, fairness, protections and preserving choice for the consumer while lowering costs. Its detractors echo similar rhetoric to the AMA of old, claiming the ACA robs Americans of their freedom to choose the medical care they deserve despite unassailable evidence that, until Obamacare, the uninsured had negligible choice to speak of for their health care needs. It remains to be seen whether the ACA will deflect its detractors and succeed in expanding health insurance to greater and greater numbers of Americans by re-injecting the idea of health care as a collective right of consumer citizenship into the US health care debate. Acknowledgements I am indebted to Regina Marchi for her invaluable feedback on an earlier draft of this paper. My gratitude also goes to the two anonymous reviewers for their helpful comments. References Abel, E.K., 2000. Hearts of Wisdom: American Women Caring for Kin, 1850e1940. Harvard University Press, Cambridge, Mass. Alexander, S.A., Frohlich, K.L., Fusco, C., 2014. ‘Active play may be lots of fun, but it's certainly not frivolous': the emergence of active play as a health practice in Canadian public health. Sociol. Health Illn. 36, 1188e1204. http://dx.doi.org/ 10.1111/1467-9566.12158. Anonymous, 1930, November. A Patient Looks at Doctors. Harper’s, pp. 710e719. Annas, G.J., 1995. Reframing the debate on health care reform by replacing our metaphors. N. Engl. J. Med. 332, 745e748. http://dx.doi.org/10.1056/ NEJM199503163321112. Ayo, N., 2012. Understanding health promotion in a neoliberal climate and the making of health conscious citizens. Crit. Public Health 22, 99e105. http:// dx.doi.org/10.1080/09581596.2010.520692. Beresford, P., 2002. User involvement in research and evaluation: liberation or regulation? Soc. Policy Soc. 1, 95e105. Beresford, P., 2010. Public partnerships, governance and user involvement: a service user perspective. Int. J. Consumer Stud. 34, 495e502. http://dx.doi.org/10.1111/ j.1470-6431.2010.00905.x. Briggs, C.L., Hallin, D.C., 2007. The neoliberal subject and its contradictions in news coverage of health issues. Soc. Text. 93, 43e66. http://dx.doi.org/10.1215/0164272-2007-011. Briggs, C.L., Hallin, D.C., 2010. Health reporting as political reporting: biocommunicability and the public sphere. Journalism 11, 149e165. http:// dx.doi.org/10.1177/1464884909355732. Bury, M., Taylor, D., 2008. Towards a theory of care transition: from medical dominance to managed consumerism. Soc. Theory Health 6, 201e219. Byrd, W.M., Clayton, L.A., 2002. An American Health Dilemma: Race, Medicine, and Health Care in the United States 1900e2000, vol. 2. Routledge, New York. Cohen, L., 2003. A Consumer's Republic: The Politics of Mass Consumption in Postwar America, first ed. Knopf, New York. ConsumerReports.org (n.d.). Our History: Timeline [Website]. Retrieved from: http://www.consumerreports.org/cro/about-us/history/timeline/index.htm. Copywriters as Physicians, 1940, July. CU's Advice to the Patient (Consumer) Is: Be Very Careful of what You Read, p. 13. Consumer Reports. Crawford, R., 2006. Health as a meaningful social practice. Health 10, 401e420. http://dx.doi.org/10.1177/1363459306067310, 1363e4593. Crenner, C., 2005. Private Practice in the Early Twentieth-century Medical Office of Dr. Richard Cabot. Johns Hopkins University Press, Baltimore. Dean, M., 1999. Governmentality: Power and Rule in Modern Society, first ed. Sage, London. Free Choice of Physician and the Fee-for-service System. Hygeia 255, 1945, April. Freidson, E., 2001. Professionalism: The Third Logic. University of Chicago Press, Chicago. Galvin, R., 2002. Disturbing notions of chronic illness and individual responsibility: towards a genealogy of morals. Health 6, 107e137. http://dx.doi.org/10.1177/ 136345930200600201. Glickman, L.B., 2001. The strike in the temple of consumption: consumer activism and twentieth-century American political culture. J. Am. Hist. 88 (1), 99e128. Goldstein, M.S., 2004. The persistence and resurgence of medical pluralism. J. Health Polit. Policy Law 29, 925e945. Grande, D., Gollust, S.E., Asch, D.A., 2011. Polling analysis: public support for health reform was broader than reported and depended on how proposals were framed. Health Aff. 30, 1242e1249. http://dx.doi.org/10.1377/hlthaff.2011.0180. Group Health Associations…are One Way to Give the Consumer the Medical Care He Deserves at Prices He Can Afford, 1940, April, p. 32. Consumer Reports. Hacker, J.S., 2008. Putting politics first. Health Aff. 27, 718e723. http://dx.doi.org/ 10.1377/hlthaff.27.3.718.

N.S. Lee / Social Science & Medicine 138 (2015) 136e143 Halle, R.S., 1931, November. Unfit Doctors Must Go. Scribner's, pp. 514e518. Hallin, D.C., Brandt, M., Briggs, C.L., 2013. Biomedicalization and the public sphere: newspaper coverage of health and medicine, 1960sd2000s. Soc. Sci. Med. 96, 121e128. Haug, M.R., Lavin, B., 1983. Consumerism in Medicine: Challenging Physician Authority. Sage Publications, Beverly Hills, CA. Health Insurance Around the Corner?, 1949, January, pp. 32e33. Consumer Reports. Health Insurance: Consumers vs. AMA, 1948, June, pp. 280e281. Consumer Reports. Health Insurance for New Yorkers, 1944, June, pp. 165e166. Consumer Reports. Hirschman, A.O., 1970. Exit, Voice, and Loyalty: Responses to Decline in Firms, Organizations and States. Harvard University Press, Cambridge, Mass. Hoffman, B.R., 2001. The Wages of Sickness: The Politics of Health Insurance in Progressive America. University of North Carolina Press, Chapel Hill, NC. Hoffman, B.R., 2002. Health care reform and social movements in the United States. Am. J. Public Health 93 (1), 75e85. Katz, N.D., 1977. Consumers Union: The Movement and the Magazine, 1936e1957 (Doctoral dissertation). Rutgers University. Retrieved from ProQuest Dissertations and Theses (7724992). Kertschner, T., 2014, May 14. For 70 Years, Most Americans Have Supported Singlepayer Government-run Health Insurance? [Website]. Retrieved from: http:// www.politifact.com/wisconsin/statements/2014/may/14/ralph-nader/70-yearsmost-americans-have-supported-single-paye/. Lawrence, R., 2004. Framing obesity: the evolution of news discourse on a public health issue. Int. J. Press/Politics 9, 56e75. Lee, N.S., 2007. Curing Consumers: How the Patient Became a Consumer in Modern American Medicine (Doctoral dissertation). UC San Diego. Retrieved from ProQuest Dissertations and Theses (3258828). Light, D.W., 2011. Historical and comparative reflections on the U.S. national health insurance reforms. Soc. Sci. Med. 72, 129e132. http://dx.doi.org/10.1016/ j.socscimed.2010.10.015. Ludmerer, K.M., 1996. Learning to Heal: the Development of American Medical Education. Johns Hopkins University Press, Baltimore. Lupton, D., 1995. The Imperative of Health: Public Health and the Regulated Body. Sage, London. Lupton, D., 1997. Consumerism, reflexivity and the medical encounter. Soc. Sci. Med. 45, 373e381. Lupton, D., 2014. Health promotion in the digital era: a critical commentary. Health Promot. Int. 30, 174e183. http://dx.doi.org/10.1093/heapro/dau091. Mahar, M., 2006. Money-driven medicine: The real reasons health care costs so much. Collins, New York. Medical care, 1939, October. Some Facts and Figures on the Way the Present Methods Work, and an Analysis of Why They Are Working Badly, pp. 17e19. Consumer Reports. Obama, B., 2007 January 25. The Time Has Come for Universal Health Care. Retrieved from: http://obamaspeeches.com/097-The-Time-Has-Come-for-Universal-Health-Care-Obama-Speech.htm. Oberlander, J., 2003. The Political Life of Medicare. University of Chicago Press, Chicago. Parsons, T., 1951. The Social System. Free Press, New York. Pew Research Center for People and the Press, 2014, June 12. Section 4: political compromise and divisive policy debates. In: Political Polarization in the American Public. Retrieved from: http://www.people-press.org/2014/06/12/ section-4-political-compromise-and-divisive-policy-debates/. Plans for economic security. Hygeia, 1935, April 302e304. Reeder, L.G., 1972. The patient-client as consumer: some observations on the

143

changing professional-client relationship. J. Health Soc. Behav. 13, 406e412. Reichert, P., 1940, February. How to be an intelligent patient. Hygeia 106e11, 160e161. Reinhardt, U., 2011. The many different prices paid to providers and the flowed theory of cost shifting: is it time for a more rational all-payer system? Health Aff. 30, 2125e2133. http://dx.doi.org/10.1377//hlthaff.2011.0813. Revolt in the A.M.A, 1937, December. A New and Progressive Program Promises Adequate Medical Care, p. 13. Consumer Reports. Richardson, 1934, January. Give Your Doctor a Break! Hygeia 10e13, 84e85. Rosenberg, C., 1987. The Care of Strangers: the Rise of America's Hospital System. Basic Books, New York. Rothman, D.J., 1991. Strangers at the Bedside: a History of How Law and Bioethics Transformed Medical Decision Making. BasicBooks, New York, NY. Ruzek, S.B., 1978. The Women's Health Movement: Feminist Alternatives to Medical Control. Praeger, New York. Sickness insurance and sickness costs. Hygeia, 1934, December 1070e1076. Silber, N.I., 1983. Test and Protest: The Influence of Consumers Union. Homes & Meier, New York. Skocpol, T., 1997. Boomerang: Health Care Reform and the Turn against Government. W.W. Norton & Co, New York. Sorenson, H., 1941. The Consumer Movement: What it is and What it Means. Harper & Brothers, New York; London. Starr, P., 1982. The Social Transformation of American Medicine. Basic Books, New York. Stevens, R., 1989. In Sickness and in Wealth: America's Hospitals in the Twentieth Century. Basic Books, New York. Stevens, R., 2008. History and health policy in the United States: the making of a health care industry, 1948-2008. Soc. Hist. Med. 21, 461e483. Stole, I.L., 2006. Advertising on Trial: Consumer Activism and Corporate Public Relations in the 1930s. University of Illinois Press, Urbana. The A.M.A. Claims, 1940, June, p. 25. Consumer Reports. The A.M.A.'s Die-hard Department, 1938, January, p. 6. Consumer Reports. The People's Health, 1939, September, pp. 17e19. Consumer Reports. The President's national health program. Hygeia, 1946, January 15. The “3c-a-day” Plans, 1939, December, pp. 17e18. Consumer Reports. Tomes, N., 2001. Merchants of health: medicine and consumer culture in the United States, 1900e1940. J. Am. Hist. 88, 519e547. Tomes, N., 2006. Patients or health-care consumers? Why the history of contested terms matters. In: Stevens, R., Rosenberg, C., Burns, L.R. (Eds.), History and Health Policy in the United States: Putting the Past Back in. Rutgers University Press, New Brunswick, NJ, pp. 83e110. Trewhella, A.P., 1943, February. Be a good patient! Hygeia 116e117, 131. Vermont Health Care for All, 2014. Stick with Act 48 [Website]. Retrieved from: http://vermontforsinglepayer.org/home. Virtual Newsstand (n.d.). Newstand: 1925: Hygeia. [Website]. Retrieved from: http://uwf.edu/dearle/enewsstand/enewsstand_files/Page4115.htm. Voluntary sickness insurance. Hygeia 554e555, 1949, August, 576. Wagner-Murray-Dingell-Bill, 1945, August, p. 216. Consumer Reports. Waitzkin, H., 2011. Medicine and Public Health at the End of Empire. Paradigm Publishers, Boulder, CO. West, E., 2014. Consumer subjectivity and U.S. health care reform. Health Commun. 29, 299e308. http://dx.doi.org/10.1080/10410236.2012.753140. Whyte, D., 1935, June. A doctor looks at his patients. Hygeia 496e500. Yost, E., 1936, January. A Patient Wants to Know. Scribner’s, pp. 47e49.