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Alexander Hamilton: What did he really say about health policy?

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“Hamilton” is one of the hottest Broadway shows there is, and it’s helped make Alexander Hamilton popular among health policy columnists.

Hamilton was Gen. George Washington’s chief of staff, one of the fathers of the U.S. Constitution, the founder of the U.S. Coast Guard, the first U.S. Treasury secretary, and the founder of the Bank of New York. U.S. currency designers have put him on one of the country’s most popular works of art: the engraving on the front of the $10 bill.

He also helped draft the laws that shaped the early government health care programs for soldiers, sailors and merchant fleet mariners.

See also: Obama to convene advisers on improving Veterans health services

David Blumenthal, the president of the Commonwealth Fund, a health policy think tank, recently argued in a widely promoted column that the current battles over the Patient Protection and Affordable Care Act (PPACA) stem, in part, from the kinds of the conflicts that divided Hamilton (who generally wanted a strong central government) from Thomas Jefferson (who was suspicious of strong central governments) back in the 1790s.

Evan Bernick argued in a column of his own that Hamilton had intended to have the U.S. Supreme Court rein in Congress and the Executive Branch, and that the Supreme Court’s moves to let the Obama administration forge ahead with implementing PPACA shows that the nation’s system of constitutional checks and balances is broken.

See also: Lessons From History

Neither Blumenthal nor Bernick gave any specific examples of what Hamilton had said or done about health policy. One of our own columnists, Jack Bobo, once noted that Hamilton was opposed to the idea of inherited wealth leaving the United States with a large leisure class, but Bobo didn’t give much detail.

See also: The Proud History Of Estate Taxes

Hamilton, who died in a duel at the age of 49, left historians huge volumes of official writings and correspondence. Google Books has put those volumes online, in a searchable format. 

One lesson a search through Hamilton’s writings reveals is that Hamilton was not always the insurance community’s best friend: In 1797, for example, he wanted the country to buy more Coast Guard boats to improve enforcement of taxes on imports. He also wanted to raise revenue by imposing major new taxes on salt, horses, perfume, hats, buildings, property passing down to nieces or nephews — and insurance.

Another lesson is that, when Hamilton was working on efforts to structure the military and mariner health care systems, he ran into many of the same types of concerns that health insurers, and your clients, run into today. His hospital for mariners was really supposed to be a disability and long-term care program as well as an acute care program: He assumed the benefit of the marine hospital program he was setting up would extend to “disabled and decrepit seamen” as well as to those suffering from acute illnesses and injuries.

For a look at some of the other things Hamilton said about military and mariner health policy, read on.

Philadelphia in 1790

1. The most obvious aim of a public health program is to maximize economic productivity.

In April 1792, Hamilton, who was then the Treasury secretary, wrote to the House speaker to say setting up hospitals made sense because hospitals could protect a “for the most part, very needy class of the community” from want and misery.

But he was not saying the federal government should pay for hospitals for all needy people. He made certain to point out that, although mariners were often needy, they were also a very useful part of the community.

Offering good hospitals for mariners could help the new United States attract good seamen, Hamilton said.

Here, the take-away for agents and brokers may be that the employers with the strongest interest in group health benefits will be those who believe group health benefits will improve their own performance as well as enhancing the well-being of the employees.

See also: PPACA World: Employer blindfold?

(Image: Philadelphia in 1790. Library of Congress/Basset)

Washington inspecting the currency

2. Money is always an issue.

In the April 1792 draft, Hamilton proposed that the seafarers who used the new marine hospitals should each contribute 10 cents per month to the fund that would pay to operate the hospitals.

Hamilton said the hospitals should probably be able to provide a small pension for patients who could work part-time and help support themselves if they lived in the community.

A take-away: The government has been trying to find good health care funding sources, and looking for ways to promote community-based care and return-to-work initiatives, for quite some time.

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(Image: George Washington inspecting the first U.S. coinage. Library of Congress/J.W. Dunsmore)

New York Narrows

3. Public health program mission creep is hard to avoid.

Hamilton did not say that the seafarers who’d be contributing to the marine hospital fund should contribute any extra for their wives and children, but he said the “widows and children of those who may have been killed or drowned in the course of their service as seamen” should get to use the marine hospitals.

The take-away: It’s hard to enforce tough benefits eligibility and underwriting standards. Even Hamilton’s heart melted for seafarers’ windows and orphans.

See also: PPACA: A history

(Image: The New York Narrows in 1798. Library of Congress) 

Provider distance

4. Balancing the need to hold down the costs with the need to make care convenient is difficult.

When Hamilton was Washington’s top aide, he drafted talking points that included a discussion of how the army of the Continental Congress was trying to improve the quality of military health care and hold down the cost.

Big army hospitals handled as much of the care as they could and hoarded military medical supplies.

The regimental forces out in the field often had to send soldiers to distant hospitals for care.

Washington and Hamilton came down on the side of offering more care out in the field, where the soldiers were when they became sick or injured, to reduce the need for regiments to send the soldiers to distant hospitals.

The take-away: Provider network adequacy was a headache for Hamilton and Washington, too. 

See also: 2,000 percent drug price surge is a side effect of FDA safety program

Quality section of 1799 military health bill draft

5. Quality matters.

Hamilton proposed in a bill draft that a physician-general should set cleanliness standards for military hospitals; prevent idleness, skulking and gambling in the hospitals; and seek to prevent the spread of infectious disease in the hospitals.

The take-away: Hospital infection control continues to be a chronic worry, but, on the bright side, hospitals do seem to have resolved the gambling problem. 

See also: 

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H.R. 3590 And H.R. 4872: A National Underwriter Guide To A New Health Reform World

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