|Development of the US Healthcare System
Christina Cruz Dominguez
Steven Dominguez, MD, MPH
In order to interpret current health policy changes and formulate predictions, one
must thoroughly comprehend the three developmental stages of the United States
health care system. The evolution of our current health care system began in 1850;
and has metamorphosed in three time periods, 1850 to 1900, 1900 to World War II
(WW II), and WW II to 2009. Significant distinct and overlapping trends in disease
prevalence, availability of health care resources, social organizations, and the public's
knowledge and perception of health and illness are associated with the changes in
each period. Herein, we will summarize each period given the four major areas of
change and will also give a prediction of the U.S. health care system in the next 30
1850 - 1900: Epidemics of Acute Infections
Epidemics of acute infections such as yellow fever, cholera, plague, malaria, typhoid,
smallpox, and influenza were the leading cause of morbidity and mortality during this
time period. Cholera alone accounted for over 5,071 deaths in New York City, and
yellow fever killed 16,500 in New Orleans over a five year period from 1853 to 1855.
These public health disasters were related to the congested and unsanitary food
supply, sewage disposal, and living conditions of the time. By 1900, these conditions
had been addressed by cities and health departments which lead to improvements in
the water works systems, sewage disposal, urban housing, and laws to safeguard
the purity of foods. Thus, those epidemics that had wrecked havoc on mankind for
centuries were virtually eliminated.
1900 - World War II: Individual Acute Events
Individual acute events such as pneumonia, tuberculosis, heart disease, nephritis,
and accidents were the leading cause of morbidity and mortality. The health care
pendulum shifted from the global disease of the population to personal diseases of
the individual. Trauma became a noted individual entity contributing to increased
individual acute morbidity and mortality.
World War II - 2009: Chronic Illness
Chronic illness such as heart disease, cancer, stroke, diabetes, arthritis, blindness,
immune deficiencies, and the effects of trauma are the leading cause of morbidity and
mortality. The discoveries of insulin in 1922, and of penicillin in 1928 revolutionized
medical care and radically changed mortality trends. People are living longer, and
chronic diseases secondary to the cumulative effects of life-style, genetics, and the
environment are apparent. Both the prevention and treatment of chronic disease
pose new challenges in that prevention requires intervention prior to the onset of
disease, and treatment cures the signs and symptoms but not the disease.
Availability of Health Care Resources
1850 - 1900: Rudimentary Home Health Care
The scientific basis of medicine was very narrow and treatments were limited.
Medical training was obtained through short coursework in unsophisticated medical
colleges or by apprenticeship. Medical care was administered at the patients home
from a black bag. Nursing care was unscientific and consisted of assisting patients
with usual body functions; and was typically administered by women of a religious
order or by women who by nature of their lifestyle frequented hospitals. Hospital
care was for the poor and destitute; since home based medical care was better than
risking additional infections in the dirty, crowded, and disease ridden hospitals.
During the typhus epidemic of 1852 in New York City, hospital staff and patients
suffered the greatest morbidity and mortality.
1900 - World War II: Birthing of Scientific Medicine
New discoveries spawn more medical research in medical colleges. In 1910, Abraham
Flexner of the Carnegie Foundation publishes his study on medical education, and
induces major medical education reform. Medical knowledge flourishes and
specialists account for 20% of physicians in 1940. Hospitals begin to embellish new
medical technology as physicians relied on the hospital as a source of access to new
technology and as a facility in which to care for their sickest patients.
World War II - 2009: Advanced Scientific Medicine
The war served as a catalyst to find and organize the best medical resources
available; this effort resulted in exponential growth in medical technology. Federal
research and development grants produces immediate war related benefits in
trauma, transportation, pharmaceuticals, and medical education. Hospitals grow in
size, number, and reputation as leading centers of medical care and research.
Physician and nursing education programs and practice centered around the hospital
and the hospitalized patient. The era of specialization is in full gear with 80% of
physicians claiming to be specialists.
1850 - 1900: Self-sufficiency
The lack of public services and the paucity of hospitals and medical care therein
necessitated a strong reliance on self-sufficiency. The predominant ethic dictated
pride in self-sufficiency and if dependency prevailed, then gratitude for the various
charities and services was indicated.
1900 - World War II: A New Deal
The ingrained philosophy of the first stage persisted until the Great Depression, at
which time reality meant dependency for the majority of U.S. citizens. President
Franklin Roosevelt implemented the New Deal, a series of national social reform
programs aimed at all impoverished citizens in an effort to rebuild the United States.
This was the beginning of a national health effort to provide medical services to those
previously denied access to medical care. Local city and county hospitals flourish as
government attempts to improve the health status of the people. The health
insurance industry is born in Texas as Blue Shield and Blue Cross.
World War II - 2009: Health Care as a Right
Tremendous government involvement in providing and assuring access to medical
care began with WW II. During the war, physicians were employed by the military to
provide medical services to military personnel as a right of their military service both
during enlistment and after discharge. Insurance companies grew as the public
demanded added benefits to employment during the war-time wage freeze. The
social climate of the '60s produced legislation to assist with the maldistribution of
medical resources; programs such as the War on Poverty, the Neighborhood Health
Centers, Medicare, and Medicaid established health services as a domain of
government intervention and regulation. These national programs fueled the rapid
growth of the health care industry. The decade of the '80s attempted to slow the
exponential expenditure on health care; Medicare was experiencing a 20% spending
increase per year and in an effort to curb rising costs Diagnostic Related Groups were
implemented. Private industry institutes the PPO, IPA and HMO models to control
sky-rocketing costs. The '90s reveal greater overall government intervention via
RBRVS and capitated reimbursement of government programs. The new decade reels
in health care as a right that is regulated and managed by the government, is the
central theme that begins and categorizes the current political and medical economic
status of the nation.
The Publics Knowledge and Perception of Health and Illness
1850 -1900: Simple-mindedness
Limited medical knowledge and self-reliance on the bodies natural healing abilities is
1900 - World War II: Optimism
The medical profession is held in high regard and in awe. Medical science is
advancing at a phenomenal rate and affecting the public health status of both the
nation and the individual. Individuals relinquish their self-reliance to their physicians.
The public believes in the medical profession and the physician.
World War II - 2009: Partnership
Medical education is disseminated during war-time education of Corpsmen and first
aid courses for the general public. The communication media becomes a vehicle of
public medical education via television and followed by the Internet. Government and
grass-roots efforts to promote health prevention lead to private industry involvement
in occupational and environmental issues. Health care is perceived as a partnership
between the patient and the industry by all parties involved, second and third
opinions are the norm.
The Nations Health in the Year 2040
Chronic disease of lifestyle, genetic makeup, and environmental exposure will
Availability of Health Care Resources
Through government rationing of health care services, infant and childhood mortality
will increase while morbidity rates decrease overall (for example, no transplants or
chronic care of invalid infants and children). Due to health care moneys and
manpower rationing to meet the needs of the nations exploding population; dialysis,
CABG, supplemental O2, mental health and long-term nursing home care is not a
government sponsored health benefit, therefore advanced medical technology is a
luxury afforded by the wealthy. This in turn will decrease the population of elderly,
hence affording a greater return in health care expenditures for the remainder of the
younger population. Hospitals are conglomerated and specialized and available only
Federal legislation mandates that all citizens belong to a defined HMO plan with a
basic package of benefits available at birth. The HMO delegates health care moneys
to meet the needs of its given constituency with long-term indicators of economic
return as a major factor; for example: well baby immunizations before elderly
immunizations. Expensive third party insurance and fee for service available for
The Publics Knowledge and Perception of Health and Illness
Health care is a right but the economic need of the nation come first.
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