Boston 1775: 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).

Source: http://boston1775.blogspot.com/2012/01/government-finance-of-health-care-18th.html

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