Segment 2 – Brief History of U.S. Healthcare

Segment 2 – Brief History of U.S. Healthcare

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In Segment 2, I will answer the question, How Did We Get Here? I’ll give a whirlwind tour of the history of medical care in the U.S., and I’ll also look at the birth of health insurance.

Let’s start with looking at healthcare in the Colonial period. The most famous doctor at the time was Benjamin Rush. He – like most reputable professionals of the day – got his medical training in Europe, in his case Edinburgh, Scotland, the leading medical center of the time. Rush was a signer of the Declaration of Independence and served in the Revolutionary Army. He became the “father of American psychiatry” because of his interest in mental illness as a disease, not demon possession.

Rush and other orthodox practitioners in the early Republic –trained in the scientific European tradition– faced competition from a panoply of practitioners in an unlicensed, unregulated “free market.” They peddled nostrums like snake oil and procedures such as blood-letting. Doctors of all types trained like apprentices. The sick were cared for in their homes, with the poor going to almshouses and mentally ill to asylums. Port cities did have public pesthouses for quarantines.

By mid-19th century, orthodox doctors began trying to solidify their place in the market. They did this through training at medical schools, beginning with Harvard, Dartmouth, College of Philadelphia (which eventually became the University of Pennsylvania) and King’s College (which eventually became Columbia). But by 1850 there were now 42 medical schools that often were little more than diploma mills. The course consisted of only two semesters of 3 months each. The medical school needed only 4 faculty, 1 classroom, 1 dissection lab and a charter to grant degrees. These schools were highly profitable.

In 1847, the AMA (American Medical Association) was founded by the orthodox physicians.

Meanwhile, the era of scientific medicine was blossoming in Austria, Britain, Germany and France. Here are some milestones – anesthesia, microbiology study of invisible germs, antiseptic surgery technique and x-rays.

In America, by the turn of the century, doctors and the AMA sought to further shore up their legitimacy by reforming medical education. States began requiring more formal education as a condition for licensure. The Association of Medical Colleges was founded in 1876. In 1893, Dr. William Welch brought to Johns Hopkins University the German model of education based on 3 or 4 years of training in clinical sciences. Industrialist and philanthropist Andrew Carnegie hired Abraham Flexner in 1910 to draw up a blueprint for medical school reform. Flexner is widely credited with ushering in the era of modern medicine in this country.

In the early 20th century, doctors enjoyed prestige and independence. Courts rules against corporations practicing medicine, ensuring the pre-eminence of private practice. Doctors joined together in hospitals to take care of growing populations in big cities, and to exploit emerging surgical and diagnostic technologies.

This brings us to health insurance. Surgery (which made great advances during the Civil War and World War I) and hospitals were becoming expensive. So in 1929, Baylor College started the first pre-paid hospital insurance. Baylor’s 1,200 teachers each paid 50 cents per month to cover up to 21 days of hospitalization. Surgeons and hospitals quickly embraced this arrangement, and the Baylor plan became the Blue Cross plan in Minnesota in 1933 and Texas in 1934. By 1950, just 15 years later, Blue Cross covered 57% of the population.

Here’s how it happened. After World War I, the war-torn countries of Europe, like Germany, were in turmoil. Social insurance, including healthcare, helped reestablish some social stability there. But in this country, politicians opposed Teddy Roosevelt’s plan to set up national health insurance for factory workers, calling public insurance a “Prussian menace”. Labor unions saw public health insurance as an encroachment on their special role to ensure worker benefits. The AMA also opposed public health insurance as a potential “interference with the practice of medicine.

Then during World War II, wages were frozen, but companies were allowed to give health insurance benefits instead. This sewed the seeds of the employer-based health insurance system. In 1948 the Supreme Court decided that unions could use health benefits in collective bargaining agreements. Then in 1954 Congress made employer-paid health premiums non-taxable. By the mid-1960s employer-paid health insurance was nearly universal.

Let’s summarize the history of medicine from Rush to Medicare. In the Colonial period and early Republic there was intense competition among doctors of all stripes, those that tried to understand the scientific basis of disease and those who peddled remedies on a trial-and-error basis (referred to as “empirical”), relying mostly on their placebo effect. We still see vestiges of this early competition today in the rivalry between MDs, DOs, chiropractors and podiatrists. During the industrial period, little by little science-based orthodox physicians in the European tradition prevailed over their rivals introducing advances in surgery, diagnosis and infection control. They shored up their gains with institutions such as the AMA, hospitals, and eventually insurance.

In the next Segment, we will look at reform movements, starting with Medicare and Medicaid in the 1960s. We will also look at why later reforms failed and where that leaves us now.

I’ll see you then.

 

 

 

 

George Washington on Leadership & Vision

https://www.c-span.org/video/?403436-1/george-washingtons-journey

Image result for george washington's journey

An exciting introduction to a George Washington we rarely see, a president who strategically traveled to all thirteen states and transformed American political culture. “Breen’s clearly written account of these sojourns give readers a fresh understanding of the president’s personality, his public and private lives, and the political and social climate of the time” (Library Journal).

During his first term as President, George Washington made arduous journeys to each of the thirteen new states. He understood that Americans did not yet feel part of a nation, and that he alone could bring them to that conviction. For Washington, the stakes were high. In scores of communities, he communicated a powerful and enduring message—that America was now a nation, not a loose collection of states. And the people responded to his invitation in ways that he could never have predicted.

In George Washington’s Journey, T.H. Breen introduces us to a George Washington we rarely meet. By nature shy and reserved, the brand new president decided that he would visit the new citizens in their own states, that only by showing himself could he make them feel part of a new nation. He displayed himself as victorious general (he wore his regal uniform and rode his white stallion) and as President (grand dinners, military parades, arcs of triumph, and fancy balls). He travelled by open carriage on terrible roads, in awful weather, staying and eating at lousy inns.

Breen takes us on Washington’s journeys. We see the country through his eyes and listen through his ears. Washington drew on his immense popularity, even hero worship, to send a powerful and lasting message—that America was now a nation, not a collection of states. In George Washington’s Journey, we come to understand why the first president is the indispensable Founding Father.

 

America Through the Eyes of the Founding Fathers

https://www.leadershipnow.com/leadingblog/2017/07/america_through_the_eyes_of_th.html?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+LeadingBlog+%28Leading+Blog%29

America Through the Eyes of the Founding Fathers

IN A LETTER from the second president of the United States, John Adams, to the Officers of the first Brigade of the third Division of the Militia of Massachusetts dated October 11, 1798, Adams cautioned the country against hypocrisy—saying one thing and doing another.

But laws he believed, could not prevent this hypocrisy. No law, no constitution could save an immoral people. While the Founding Fathers believed in the necessary separation of Church and State, they believed no discussion of morals was possible without an agreed upon philosophy – a philosophy that superseded the logic of men. So Adams concluded that “Our Constitution was made only for a moral and religious people.”

George Washington also said as much halfway through his Farewell Address of 1796. He stated: “Of all the dispositions and habits which lead to political prosperity, Religion and morality are indispensable supports.” He added, “And let us with caution indulge the supposition that morality can be maintained without religion. Whatever may be conceded to the influence of refined education on minds of peculiar structure, reason and experience both forbid us to expect that National morality can prevail in exclusion of religious principle.”

Both Adams and Washington are appealing to a morality that was eternal—beyond the customs of man. A morality that didn’t shift on convention.

John Adams wrote to the Massachusetts Militia:

While our country remains untainted with the principles and manners which are now producing desolation in so many parts of the world; while she continues sincere, and incapable of insidious and impious policy, we shall have the strongest reason to rejoice in the local destination assigned us by Providence.

But should the people of America once become capable of that deep simulation towards one another, and towards foreign nations, which assumes the language of justice and moderation, while it is practising iniquity and extravagance, and displays in the most captivating manner the charming pictures of candour, frankness, and sincerity, while it is rioting in rapine and insolence, this country will be the most miserable habitation in the world.

Because we have no government, armed with power, capable of contending with human passions, unbridled by morality and religion. Avarice, ambition, revenge and licentiousness would break the strongest cords of our Constitution, as a whale goes through a net. Our Constitution was made only for a moral and religious people. It is wholly inadequate to the government of any other. Oaths in this country are as yet universally considered as sacred obligations. That which you have taken, and so solemnly repeated on that venerable ground, is an ample pledge of your sincerity and devotion to your country and its government.

James Madison, the fourth President of the United States, believed that the governed were obliged to control itself. Furthermore, it was the responsibility of a virtuous people to select leaders that would reflect that ideal. Leaders that would be capable by virtue of their own character, adapt these eternal morals that Adams often spoke of, to particular circumstances. Madison wrote:

But I go on this great republican principle, that the people will have virtue and intelligence to select men of virtue and wisdom. Is there no virtue among us? If there be not, we are in a wretched situation. No theoretical checks–no form of government can render us secure. To suppose that any form of government will secure liberty or happiness without any virtue in the people, is a chimerical idea. If there be sufficient virtue and intelligence in the community, it will be exercised in the selection of these men. So that we do not depend on their virtue, or put confidence in our rulers, but in the people who are to choose them.