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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
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
• 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.
• Invention of microscope-van Leeuwenhoek
• Pasteur (1860s)
• Semmelweis (1840s) – hand washing
• Lister (1860s) –antiseptics
• Koch (1870s) – microbe with disease
• Fleming (1920s) – penicillin
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
• 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
• 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
• 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
Chester County Hospital 1924
St Vincent Depaul Norfolk, VA/Catholic Daughters of CharityNSU 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 100year long commitment to excellence by Highton, M. (1988)
• 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
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
Effect of World War II
New technology
New professions
Advanced Education
– 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
• Great Society
• 1965/1966 Medicare
and Medicaid – care
paid for by the federal
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
– Negotiated contractual agreements between the
physicians and insurance company
Stakeholders in Health Care
Low cost/good
Profit/Good Care
Insurance Co.
Low cost/good care
Health Care
Good Reimbursement/ Quality 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
• United States is the only developed country
without a national health care plan!
– Why???
Other Considerations
• Portability
– 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
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