Dorothy Rice—who passed away on February 25, 2017, at the age of 94—was a giant in the field of health services research, conducting groundbreaking studies, and mentoring others who continue to contribute to the field. Her pioneering study of health insurance coverage of the aged based on the 1962 Survey of the Aged was instrumental in the enactment of Medicare. It was in this study that Rice found that half of the population age 65 and over was uninsured at the time. She also noted that those most in need of health insurance were those least likely to have it—persons in poor health, the very old, those not employed, and those with low incomes. Her research quantified and defined that harsh reality in a way no one ever had before. Indeed, the financial risk of expensive hospitalization and the potential financial burden of medical bills was a major propellant of the Medicare legislation.
Rice’s first major public health leadership role was heading the Medicare research division at the Social Security Administration. Serving as Deputy Assistant Commissioner of Social Security, she had the wisdom to ensure the collection of pre-Medicare data to contrast with Medicare program data to assess the impact of the program on access to care and health care costs. She led the design of the Medicare data and statistical reporting system, including Medicare enrollment data, samples of Medicare claims, and the launch of the Medicare Current Beneficiary Survey to track beneficiary access to care. This rich data repository is the source of much of the ensuing decades of research on the US health system performance—far easier to access and analyze than data on privately insured individuals covered under multiple independent insurers or Medicaid program data from states and territories.
In 1970, Dorothy came across the doctoral dissertation on hospital costs that I had just completed the previous year at Rice University. She recruited me to her staff as a Brookings Economic Policy Fellow to analyze hospital cost reports on a sample of hospitals from 1961 — 1969. At the time, the competing theories of cost growth were “demand-pull” versus “cost push.” The “demand pull” theory viewed insurance as shifting the demand curve for health care upward, thus increasing the price at which demand and supply intersected. An expansion of the supply of physicians was believed to lower prices. The “cost push” theory viewed nonprofit hospitals as motivated to spend whatever revenue they received. An increase in revenue, especially one based on cost reimbursement, induced hospitals to increase costs. Our research published by the Social Security Administration and in economic journals favoring the “cost push” theory contributed to the evolution of the Medicare hospital prospective payment enacted in 1983.
Dorothy was also a pioneer when it came to developing the methods that continue to provide the foundation of our field’s approach to research and analysis. She, along with Barbara Cooper, took responsibility for the national health expenditure accounts published originally by the Social Security Administration and now by the Centers for Medicare and Medicaid Services. They enhanced the data sources and strengthened the methods, providing us with rich consistent historical data on trends in health expenditures by type of services and payer.
But Dorothy’s impact on our field was not just a function of her sharp intellect and rigorous research. It was her outgoing, warm personality that endeared Dorothy to all. I quickly learned that simply saying her name and signaling Dorothy’s commitment to a project, opened doors to her vast network of colleagues, friends, and admirers. And it was in great cooperation with this community that we obtained important data that ultimately led to key insights about health and health care that policy makers continue to build on and respond to today.
The Economic Cost Of Illness
Dorothy also led the way in conducting an economic cost of illness study that encompassed all disease categories. She was galvanized by the studies of different disease societies whose costs of illness in the aggregate, Dorothy asserted, came to more than twice total health spending. Reflecting an awakening about the economic contributions of homemakers, the studies included not only the direct cost of illness but lost productivity from work in the labor -force as well as homemaking and caregiving services.
Dorothy left the Social Security Administration in 1976 to head the National Center for Health Statistics (NCHS) where her first major project was to develop the annual report, Health U.S., which makes accessible to every health policy analyst key data from vital health statistics to health expenditures. She also created new ways of tracking health outcomes, such as the creation of the National Death Index, making it possible to link survey data on individuals’ health and health care utilization to subsequent mortality.
After leaving NCHS to join the faculty of the University of California, San Francisco (UCSF) Medical School in 1982, Dorothy went on to conduct studies on the economic costs of most major diseases such as Alzheimer’s and HIV/AIDS. Her work on the economic cost of smoking was particularly influential: Dorothy’s analysis of the increased state Medicaid costs due to smoking helped shape the magnitude of the 1998 tobacco Master Settlement Agreement. At a point in her life when many people would have retired, Dorothy had some of her most productive years conducting research at UCSF.
A Remarkable Mentor
Over her career, Dorothy authored more than 200 monographs, books, articles, and book chapters on the economics of health care, aging, chronic illness, disability, health statistics, and cost of illness. But as significant as her professional accomplishments were, Dorothy stands out to me for her warmth and lively interest in those around her. She was generous with credit and once said, “There is no end of good you can do if you don’t care who gets the credit.”
She was also the most prominent woman in health care research and policy, just as the women’s movement came to the fore. At the Social Security Administration, Dorothy made an extra effort to support the women who worked there. It was thanks to both her encouragement and her example, that women were not only accepted but given major responsibilities and helped to flourish.
In the decades that followed, Dorothy would excel as a mentor. Most people think of mentors as people who give their mentees wise advice. Dorothy did more than that. She passed along opportunities to speak at professional meetings and even extended social invitations to introduce mentees to influential thinkers.
I never stopped asking her for advice and help—and, even in her nineties, Dorothy was always sharp and on target with her suggestions. She kept abreast of the latest research and policy developments and took a keen interest and pride in her family, students, and colleagues.
Her most important lasting legacy includes the legions of those she inspired and influenced to carry on her valuable work to preserve and strengthen public health programs such as Medicare and Medicaid.
