Lecturer: Monika M. Wahi, MPH, CPH
At the end of this lecture, student should be able to: Name at least three characteristics of health care delivery in pre-industrial America Name at least one notable development in medicine in the U.S. in the post-industrial era, and describe why Explain at least one reason why national health care has failed in the United States Describe at least two differences between Medicare and Medicaid
Knowledge of U.S. health care history necessary for understanding today’s system System’s historical foundations help explain why America has resisted universal health insurance Despite many forces of change, health care still a private industry receiving financing from the government. Ironically, despite private and public sources of financing, many people in the U.S. still go without health insurance
Cultural Beliefs and Values • Self-reliance • Welfare assistance only for the most needy Social Changes • Demographic shifts • Immigration • Health status • Urbanization Technological Advances • New treatments • Training of health professionals • Facilities and equipment
Economic Constraints • Health care costs • Health insurance • Family incomes Political Opportunism • President’s agenda • Domestic and foreign priorities • Party politics • Power of interest groups • Laws and regulations
Science and tech advances make care in U.S. highly specialized Basic and routine care given secondary importance Providing latest treatments which are highly used by the population ↑ cost As insurance is extended to more Americans, that cost must be contained
Medical training and education not grounded in science Primitive medical procedures were practiced. Intense competition existed because any tradesman could practice medicine From Exhibit 3.2 on page 56.
People relied on family members, neighbors, and publications for domestic remedies Physicians’ fees were paid out of personal funds Health care was delivered in a free market From Exhibit 3.2 on page 56.
Hospitals were few and located only in big cities Hospitals had poor sanitation and unskilled staff Almshouses served the destitute and disruptive elements of society and provided some basic nursing care From Exhibit 3.2 on page 56.
State governments operated asylums for patients with untreatable, chronic mental illness. Pesthouses quarantined people with contagious diseases. Dispensaries delivered outpatient charity care in urban areas. From Exhibit 3.2 on page 56.
Until around 1870, medical training through apprenticeship (rather than university) Ironically, those doing the training themselves were poorly trained! Training a class could make more money than just training individual apprentices, so some tried to open schools Lack of facilities and ability to confer degrees prompted these “physicians” to affiliate with local colleges In 1850, about 42 of these “medical schools” were in operation in the U.S.
Year 1: Attend 3-4 months of courses Year 2: Repeat the same 3- 4 months of courses. Graduate with a 2-year MD degree.
PRACTICE EXAMPLES A barber sells herbal Anyone could practice prescriptions in his shop. medicine. A woman gives birth at home Medical procedures with just the help of her sisters and mother. primitive. A tailor who doubles as a doctor No rigorous course of study, visits the home of a boy cut by a sharp rock and sews up his most physicians with little wound actual expertise. A church pools its funds to have Low status, often side job for a doctor visit its pastor, who has been bedridden with a extra income. mysterious illness. The doctor Most families bleeds him, and gives him Preferred self-reliance herbal concoctions and enemas. Could not afford physicians’ fees
UNITED STATES EUROPE A few isolated hospitals: France and Great Britain NYC, Boston, New Orleans, expanded hospitals long St. Louis, Philadelphia before 1800s Characteristics: Medical professions Unsanitary readily adopted new Poor ventilation Unhygeinic science Nurses unskilled and untrained Considered advanced More dangerous than staying home! “Houses of death and institutions of welfare”
1. Almshouse A. A. Often staffed by medical Often staffed by medical students, this place provided students, this place provided (poorhouse) drugs to patients drugs to patients B. B. Goal was to contain the spread Goal was to contain the spread of communicable disease of communicable disease C. C. For patients with chronic, For patients with chronic, 2. Asylum untreatable mental illness. untreatable mental illness. D. D. Served people with cholera, Served people with cholera, smallpox, typhoid, or yellow smallpox, typhoid, or yellow 3. Pesthouse fever. fever. E. E. Served elderly, homeless, Served elderly, homeless, orphans, ill, and disabled. orphans, ill, and disabled. 4. Dispensaries F. F. Residents were called inmates. Residents were called inmates. G. G. Bleeding, forced vomiting, and Bleeding, forced vomiting, and hot and ice-cold baths used. hot and ice-cold baths used. H. H. Outpatient clinics to provide Outpatient clinics to provide free care to those who could free care to those who could not pay. not pay.
In aftermath of Civil War (1861-1865) In 1840, 11% U.S. population in urban areas, but in 1900, increased to 40% How did this change family-based care? How did this change where medical services were offered? Increasing driven by science and technology. Good effects: Advances in x-ray technology. Other good effects? Bad effects: Rise in cost. Other bad effects? Pressures of science/tech led to pressures for physicians to specialize Implications for care coordination?
ANESTHESIA HANDWASHING • 1847 PASTEURIZATION ANTISEPTIC SURGERY ADVANCES IN X-RAYS PENICILLIN • 1846 • 1860 • 1865 • 1895 • 1929 • Ignaz • Horace • Louis • Joseph • Wilhelm • Alex- Semmel- Wells Pasteur Lister Roent- ander weis gen Fleming • Dentist • France • Carbolic • Hungary acid to • Germany • Anti- • Surgery, • Germ /Vienna wash bacterial quick theory • Radi- wounds prop- • High ampu- of ology erties of death tations disease the first penicillin rate machine from -based child- medical birth specialty From Exhibit 3.4 on page 61.
Since 1847 (pre-industrial), took a back seat to uncoordinated actions of individual physicians competing in marketplace During post-industrial era Organized members into state- and county-level societies Started controlling medical education Lobbied states for medical licensing laws Discouraged “corporate control” – physicians working for hospitals or insurances AMA succeeded! Prescriptions require physician authorization, health insurance only pays when prescribed by physician, etc.
1. 1869-Howard A. A. Found widespread Found widespread inconsistencies in medical inconsistencies in medical University School of training. training. Medicine B. B. Established to prepare black Established to prepare black 2. 1871-Harvard Medical physicians to practice medicine physicians to practice medicine School C. C. Changed entrance requirements Changed entrance requirements 3. 1876-Meharry to medical school to include an to medical school to include an undergraduate degree, not just undergraduate degree, not just Medical College high school diploma high school diploma 4. 1893-Johns Hopkins D. D. Formed by AMA, it pushed for Formed by AMA, it pushed for University state laws requiring graduation state laws requiring graduation 5. 1910-Flexner Report from medical school for from medical school for 6. 1910-Council on licensure. licensure. E. E. Changed the academic year to Changed the academic year to Medical Education follow the European model follow the European model
The industrialization of medicine Physicians could no longer afford equipment, facilities, etc. Hospitals needed physicians to keep their beds filled Informal alliances between physicians and hospitals – physicians were not employed there, but had a strong say in hospital operations As more hospitals became available, competition for physicians’ patients started to influence hospital policy
Scientific Hospitals Creation of Medical Power and Organized Discoveries/ True Medical Medicare Urbanization Education Prestige of Medicine Applications Care and Reform Physicians in Medicine Institutions Medicaid • Advanced science-based • Control over medical training treatments • Increased health care costs • Powerful political interest group • Growing imbalance between • Support of licensing laws • Opposition to national health insurance proposals specialists and generalists • Support of private entrepreneurship in medical practice From Exhibit 3.3 on page 60.
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