Guerilla Health Care - 03

This is the third in a series of contributions to fixing the health care system without breaking the bank

Very simple story of how the health care system got this way

The health care system, continuing a tradition of medicine going back centuries, was propelled forward in the 20th Century by a combination of three factors:  the growth of health insurance, exponential progress in medicine, and the increased role of the federal government in health care.

Health Insurance. Universal health care and national health insurance were proposed as far back as the presidency of Teddy Roosevelt, but were opposed, for a variety of reasons, by organized medicine, organized hospitals and the insurance industry (and their policy spokespersons in government).  There was nothing like private health insurance in the US until 1929.  The reasons are numerous, but in part it was that medicine, in the early 20th Century, was a pretty uncomplicated affair.  Much of it was conducted in the home, fees for service were modest enough they could be paid out of pocket, and there was a tradition of pro bono or charity medicine for those who couldn’t afford care.

The Great Depression spurred the introduction and growth of private insurance, the labor movement accelerated it as health insurance became a negotiable benefit, and by the 1940s it was a not-uncommon commodity.  What emerged, however, was a mish-mash of  coverage, with few or no standards, no coordination and continued opposition to any kind of planned health care system.

Progress in Medicine. In the meantime, there were advances in public health that changed the major causes of death among Americans—we began to live longer—and the same was true of medicine.  There was, for example, a dramatic decrease in the rate at which women died in childbirth as more and more births were attended by physicians in hospitals.  There were advances in the understanding of variations in human blood, making transfusions less risky and enhancing the survival of surgical patients.  Likewise, antibiotics changed what we died of probably more than anything since the introduction of pure drinking water through municipal systems.

Infusion of Government Funds. Still, at the end of World War II, there had been decades in which the supply of hospital beds hadn’t kept up with need.  With rapidly improving medical technology, a general advance in affluence, the existence of affordable health insurance, it was considered necessary by the federal government to intervene by adding to and modernizing hospital facilities.

In 1946 Senators Harold Burton and Lister Hill fashioned a bill to provide federal construction funds for hospitals in areas with shortages of hospital beds.  In California, where I am familiar with the program, the state matched the federal funds and together these amounted to two-thirds of the cost of construction, the other third being raised by bank loans, philanthropic donations or private capital.  At about the same time, the National Institutes of Health and the National Science Foundation began to rapidly increase public monies available for health and biomedical research.  Both root causes of disease and dysfunction as well as therapies aimed at preventing death or long-term disability created another great leap forward.  The focus turned from communicable diseases, which had been tamed largely through public health measures, to the prevention and treatment of chronic diseases, such as cancer.

As we became a predominantly urban society, with a burgeoning middle class, the diseases of affluence plus changes in the people’s expectations increased the demand for health care services as well as the cost of care.  Cost became no consideration in decisions about conditions which, forty years earlier, might have been borne with resignation. With the advent of Medicare in 1966, a class of patient—retired persons of modest means—that had traditionally counted on family and charity to attend the illnesses of advanced age, became a steady source of income for, particularly, hospitals.

Policy makers still had no consistent vision of what constituted a proper health care system, nor what should be the government’s role in operating it.  Some favored federal intervention concentrated on the treatment of catastrophic illness, such as end-stage renal disease; others favored a system that concentrated on preventing illness, and for a time health maintenance organizations were seen as a way to keep ever-increasing costs down while preventing chronic illness and disability.

The question is far from settled.  According to the National Coalition on Health Care, in 2008 we spent more on health care than on defense, or some 17 percent of the nation’s wealth.  We are continually told by organized medicine, hospitals and insurance companies, despite evidence much to the contrary,  that universal health care, with a single payer, is inferior to our laissez faire catch-as-catch-can system because you will have bureaucrats making medical decisions.

In 1929 many Americans were lucky to get any medical care (other than “folk medicine”) between birth and death, and even those defining events might be outside a hospital.  In 1969 by contrast, the average person spent three of his last twelve months of life in an acute care hospital.

And sometime in the ‘70’s, in Los Angeles, Mabel’s friend got her CAT scan because she had a headache.


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