“Understanding Healthcare: A Historical Perspective” is a new e-book in which I attempt to address the challenges facing physicians today in part by reviewing the history of healthcare.
Physicians strive to serve patients, relieve suffering within the limitations of today’s knowledge, enhance public health, prevent epidemics, and to cure or minimize the scourge of disease.
But, lest we forget, at the heart of medicine is a forthright and sincere human-to-human interaction. It is deeply personal with a mutual understanding that this is different from the casual or commercial transaction. It is intimate with far reaching consequences. Policies today that are being promulgated from Washington actually impede this relationship, harm care, and increase cost.
Entrenched Ideas Even if Incorrect Tend to Last
Medicine’s ability to help patients is a relatively new phenomenon, founded on discarding dogma and replacing it with evidence-based concepts. For most of human history medicine was based on unproven ideas first enunciated by ancient Greek scholars. Blood, yellow bile, black bile, phlegm and their proper balance were considered the foundation of health.
In sickness the physician’s duty was to rebalance these forces using unpleasant and at times deadly therapies. Before advances could come about, significant changes in thinking had to occur. Brilliant minds had to come to the conclusion that before adopting a line of reasoning, observation and the continuous refining of concepts based on data needed to occur. The scientific method was introduced to medicine, as was, perhaps, the key to man’s ever-increasing knowledge.
I ascribe the beginnings of this process to 2 physicians, both publishing in 1543. C.E. Nicolaus Copernicus was the first to state that the Sun and not the Earth was the center of the solar system. Andreas Versalius found that Galen’s (Greek physician to Roman emperors) descriptions of human anatomy were wrong and then published various insightful woodcuts. Thinkers such as Rousseau, Voltaire, Locke and others during the Enlightenment—late 17th to 18th Centuries—spoke about the power of the human mind and the value of every individual.
The Beginning of a Different Approach to Medicine
In the 19th Century there were discoveries that even today are the foundations of modern medicine. Concepts regarding vaccination, bacteria, viruses, and parasites as vectors of disease were first described. Anesthesia, aseptic surgery, the causes of puerperal fever, the stethoscope, blood pressure determination, radiology, psychiatry, and modern pathology were among the outpouring of advances during this period.
But in the newly created U.S., the future of medicine was contested. Although a number of university medical schools were created, the University of Pennsylvania being the first in 1765 , the numbers of graduating physicians were few. By the early 1800’s about 60% of all medical practitioners did not consider themselves to be medical doctors, instead following other non-scientific concepts of health (homeopathy, etc.). To meet this challenge local medical societies and groups of physicians created proprietary medical schools and apprenticeships. They had no entry criteria or standardized curricula, clinical requirements were sparse and inconsistent, and times of study were brief or varied. These schools’ primary function was profit.
A few medical leaders were convinced, as the many scientific advances made in Europe were unfolding, that medicine was undergoing a scientific transformation and that physicians had to be rigorously trained in science while at the same time understanding the paramount importance of the patient-physician relationship.
Into this foray entered Nathan Smith Davis, MD. In 1846. As a delegate to the New York Medical Society of Medicine he proposed the creation of a national medical society that would promote educational standards and qualifications for physicians. In 1847 this organization was born as the American Medical Association (AMA). Dr. Davis was a force in this effort and the AMA—by the early 20th Century—was able, along with the Carnegie Foundation, to set standards that caused proprietary schools to close.
A major step in promoting AMA-sponsored, scientifically based medicine came about in 1889 when the U.S. Supreme Court in Dent v West Virginia agreed that states had the right to license physicians along criteria established by West Virginia’s AMA members.
Struggling with Success
As medicine became more effective, the question was how a society would ensure that patients and physicians would benefit. Was it in a society’s interest that all citizens remain as healthy as possible throughout their lifetimes and to contribute to the limits of their capabilities? With this thinking it is thus not a gift, but an investment.
Also national governments sponsor medical research for all to benefit. The first to answer this challenge was Otto von Bismarck, Chancellor of Germany, who in 1883 initiated a health plan for the poor as a benefit of the state, not a payment directly to the patient. Following this lead, instead of providing funds for individuals to obtain self-directed care, state structures became the norm. In 1911, David Lloyd George reproduced the German plan in Great Britain, which in 1948 was expanded to become the National Health Service.
In the early 20th Century care for the poor was considered by the AMA; however, by about 1920 the Association, without offering alternatives, refused to consider and fought any plan providing healthcare for the needy, as they were wary of altering the patient-physician relationship. During World War II, because of wage controls, pre-tax health benefits were made available to employees. This left the poor and retirees without coverage. Then, in the U.S., there ensued a flurry of political activity to find a solution. Unfortunately, the AMA was obstructionist and did not offer creative patient-directed solutions. In 1965 following a landslide election, President Johnson was able to pass Medicare/Medicaid, a state dominated rather than individual directed program resulting in many unintended negative consequences.
As 3rd party, government, and insurance companies became more dominant, bureaucracy greatly increased while sacrificing the patient-doctor relationship. This has caused costs to erupt, pricing more Americans out of the insurance market. The answer, following the same pattern of thinking, became more state-centered attempts to deal with increasing costs and decreasing coverage. They were the HITECH Act (2009) and the Affordable Care Act (2010) and following the same pattern neither have controlled costs with still millions not or inadequately insured
A Better Way
A better solution would be to give individuals the choice of staying with government directed care or controlling their own funds. Being in charge of one’s funds via patient-directed care has proven successful in other countries and a Medicaid pilot in Indiana. For those wishing to do so, make yearly actuarially determined payments for Medicare recipients to be deposited into a health account to pay cash for routine care and to purchase high deductible insurance available nationally. Allow participants younger than a specified age to deposit payroll Medicare withdrawals into a health account consisting of half bonds, the other stocks. Perhaps after 50 years of government dominated care we would give Americans an option of a different approach to solve the problem of making good care available to the entire population at a cost our society can afford.
By Kenneth A. Fisher, MD
The views expressed in this article do not in any way represent MDalert.com. They are the personally held views of Kenneth A. Fisher, MD.