History of Health Care in the United States

HRP 290

The Beginning

• Hippocrates – 460 B.C.– Beginning of medicine as we know it– Systematic observations not superstition– Ethical principle which form our current ethical

guidelines

Hippocratic Oath

• I will apply dietetic measure for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice. I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly I will not give a woman an abortive remedy. In purity and in holiness I will guard my life and my art.

• I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.

European

• Invention of microscope-van Leeuwenhoek (1670s)

• Pasteur (1860s)

• Semmelweis (1840s) – hand washing

• Lister (1860s) –antiseptics

• Koch (1870s) – microbe with disease

• Fleming (1920s) – penicillin

AMERICAN EARLY SETTLERS

• No Formally trained physicans/nurses

• Treatments word of mouth “old wives tales”

• Used herbs and home made concoctions

• Women cared for house, children and those that were ill

First Physicians in America

• English system-physicians, apothecary and chirurgeon

• Few university educated physicians came to the new world

• “A few physicians among us are eminent for their skill. Quacks abound like locusts in Egypt, and too many have been recommended to full practice and profitable subsistence” Smith, 1758, History of New York

First Medical Training

• 1756 College of Philadelphia (Univ. of Penn)

• 1768 King’s College (Columbia)

• Most trained in an apprenticeship process

• Process unregulated and unstructured

American Medical Association

• Founded in 1847

• Goal to improve medical education

• Common goal difficult; Not see need to change (note that Pasteur, Koch and Lister had not made impact)

• Abraham Flexner headed a study of medical education (The Flexner Study)

Medical Practice

• Medicine was not a field that provided wealth or prestige

• Many had to have second jobs

• Physicians had no need for hospitals

• Patients treated at home and care for by families or hired help

Hospitals

• Very few hospitals; physician had little need; more affluent stayed at home

• Three kinds– Pest houses– Almshouses– Marine Hospital– Seamen’ Act

• Seen as a place to go to die!• Changed in 1900’s with improved sanitation,

decrease in hospital acquire infection and antiseptics introduction

www.cchosp.com/images/history/history_ben_03.jpg

Chester County Hospital 1924

St Vincent Depaul Norfolk, VA/Catholic Daughters of Charity- NSU Historical Archives

Norfolk State University Archives

1888 Women’s Christian Association/ 1898 Norfolk Protestant Hospital

From: Words of honor : the story of Sentara Norfolk General Hospital's 100-year long commitment to excellence by Highton, M. (1988)

Nurses• Not a “suitable profession” is

18th and 19th century• Most healthcare provided by

Catholic Nuns• Florence Nightingale 1850’s

– Leave your shackles and become a nurse

– Reformed the health care of soldiers during the Crimean War

http://www.florence-nightingale.co.uk/flo2.htm

Health Insurance

• No such thing as health insurance existed

• Until----- “Birth of the Blues”

• 1929 Baylor Hospital– 50 cents a month– 21 days of hospital care at Baylor Hospital

• Beginning of employer provided health insurance

Effect of World War II

• New technology

• New professions

• Advanced Education

• Suburbanization– Hill Burton Construction Act

• Changes is social norms

• Birth of “Baby Boomers”

Circa 1944

National Library of Medicine

Those without Health Care

• President Lyndon Baines Johnson

1963-1969• Great Society• 1965/1966 Medicare

and Medicaid – care paid for by the federal government

http://www.whitehouse.gov/history/presidents/lj36.html

Fast Forward To 1980s• Federal Government saw rapidly rising

cost and anticipated even larger increase• Why?

– Technology– Population Growth– Inflation

• Payment systems– Retrospective– Prospective

Prospective Payment System

• DRGs (Diagnostic Related Groups)

• Health Maintenance Organizations (HMO)– Primary Care Physician/Gatekeepers– Control cost by controlling referrals, drugs, and

hospitalizations– Negotiated contractual agreements between the

physicians and insurance company

Stakeholders in Health CareEmployers

Patient/Employees

Health Care Providers

Insurance Co.

Low cost/good care

Low cost/good care

Good Reimbursement/ Quality Care

Profit/Good Care

Health Care System (?)

• Massive– as of 2005 Census– 2.4 million nurses

• Projected to grow by 623,000 by 2012– 7,569 hospitals that employ 5.1 mil people– 819,000 Physicians– 77,000 Occupational Therapists– 182,00 Physical Therapists– 94,000 Respiratory Therapists– 18,000 Nursing Homes with 1.6 residents

• State with largest Number?• Potential for growth?

National Health Care System

• First proposed in 1940s

• Reintroduced in 1993-2000 Clinton presidency

• United States is the only developed country without a national health care plan!– Why???

Other Considerations• Portability

– HIPAA– Cobra– Continuity of Care

• Pre-existing conditions• More cost being passed on to employee• Cost is the same regardless of salary• Rationing of Health Care

– Based on ability to pay– Based on health history– Based on lifestyle