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Abstract

Unexpectedly, the use of health care services has been found to differ substantially across subgroups of a population covered by health insurance. In the Medicare program, persons at risk of poor health tend to use fewer of the types of services that healthier persons use to improve health and prevent disease. Relatively little is known about why patterns of health care among the elderly differ by race and socioeconomic status (SES). That disparities occur so persistently in a program such as Medicare, which was expected to equalize access to care, indicates that there are limitations to what health insurance alone can do to assure equal access to health care. The challenge is to determine what our society can do to ameliorate disparities in health care. Health policy experts from an earlier era can provide some insight into the dilemma of disparities in health care. Two books, published half a century ago, contain papers by members of the New York Academy of Medicine on social medicine, a term intended to evoke the complex interrelationships between health and society. Social medicine was defined in one paper as "medical science in relation to groups of human beings." Underlying the concept of social medicine was the belief that medical science ought to approach health, notjust in terms of treating a patient's illness, but also in terms of the whole of an individual's life and society. The multitude of factors that influence health status and health care led one member of the Academy to observe that the problem of medical care is "more complex than it is taken to be." One paper noted that social security and welfare programs do not change the existing social and economic order but mitigate the hardships created by it, noting (with considerable prescience) that health insurance "does not guarantee health to the insured wage earner nor yet does it make public health measures superfluous." To understand the influence of poverty, education, and occupation on health, members of the Academy advocated an expansion of medical school curricula to include knowledge from the social sciences. As one writer stated, "Medicine's recognition of the part the social sciences play in the total health, either of the individual or of groups, will constitute a milestone in human progress. "

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