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Historical Overview of Healthcare in the United States

It is important that each healthcare professional has an understanding of how and why healthcare exists in its current form today and what it was like in the early years of the United States.  Cultural, social, technological, economic, and political forces have forged the path of healthcare delivery over time in the United States Healthcare System (Shi & Singh, 2019).  By reviewing the history of the United States Healthcare System and the organizations that comprise it, you will gain a full understanding of our healthcare system has evolved. 

The first written account of medicine and even written prescriptions can be traced back 4,000 years ago in Mesopotamia.  Fast forward 1,000 years in Greece where Hippocrates changed the realm of medicine forever where he began performing surgical and other medical procedures that he carefully documented, providing historians valuable information regarding his insight into medicine.  The first resemblance of the modern hospital was built in India around 600 BC where more sophisticated healthcare began to be offered, such as cesarean section.  People did not necessarily go to the hospital when they were sick, it was more so if they were dying or had a contagious disease.  The Islamic civilization made enormous contributions to the field of medicine and their hospitals were considered the best of their time.  As time progressed, the Middle Ages are known for great hospitals and the Renaissance was a period known for great medical schools (Wolper & Pena, 2011).  In the 1400s, hospitals were built in the New World (colonies of Spain, France, and England) and by the 1700s, the United States had its own hospitals.            

In its infancy, the United States Healthcare System had only a handful of hospitals and no healthcare insurance existed.  Healthcare was often purchased through bartering or personal funds.  Benjamin Franklin sought to build a hospital that would treat patients with dignity and respect whether payment could be made or not.  The Pennsylvania House was built in 1751 and became the model in which all other hospitals would be modeled after.  However, healthcare in the United States was still limited, unsanitary and even unsafe.  Medical training was largely received through apprenticeship and the medical schools that did exist held low standards and were built around a poor curriculum.  Medicine, in essence, was a nonprofessional practice in the early stages of American Healthcare and was merely a trade.  Barbers were common medical tradesmen and the red-and-white striped poles (symbolizing blood and bandages) signified they were practicing surgeons in their time. 

Almshouses, also known as poorhouses, were some of the very first hospitals in the United States.  Almost every city in the country had an almshouse, which was commonly operated and funded by local governments.  While they were not necessarily hospitals, they housed anyone who needed a form of care, from the elderly to the orphan.  Living conditions were often characterized as filthy and deplorable.  Asylums were also commonplace and are considered the nation’s first inpatient psychiatric facilities.  The first outpatient clinics in the United States, also known as dispensaries, provided basic medical care and prescription medicine to anyone who needed it.             

In the 1900s, technology and science began to really drive how healthcare was delivered in the United States.  Science-based medicine created a huge demand for healthcare services that could no longer be offered through family and friends.  The progress made in the fields of bacteriology, antiseptic surgery, anesthesia, immunology, and diagnostic techniques moved the healthcare profession into a legitimate one (Shi & Singh, 2019).  While healthcare institutions began to improve in the 1900s, so did medical education.  In 1910 Abraham Flexner, a researcher for the Carnegie Foundation, inspected every medical school in the country and found widespread inconsistencies.  His report, known as The Flexner Report, was the impetus for medical reform and standards and also resulted in many medical schools to accept reform or shut their doors.

In 2019, the United States healthcare spending reached a staggering $3.8 trillion, or $11,582 per person (Centers for Medicare & Medicaid Services [CMS], 2020). The rising costs of healthcare coupled with sometimes-mediocre quality, outcomes, and access and spurned the necessitation for healthcare reform in the United States. The first instance of health reform in the U.S. came in the form of an act passed by the Fifth Congress on July 16, 1798, that levied a tax on the employers of merchant seamen which was meant to fund arrangements for their healthcare through the Marine Hospital Service (Longest, 2016).  

In the United States, the term healthcare reform is used to describe the extension of health insurance to the uninsured (Shi & Singh, 2019).  The United States Healthcare System continues to struggle to control costs and improve access and quality.  Several pieces of federal legislation have been enacted to attempt to improve healthcare cost, quality, and access but the pace for improvement and reform is slow due to the complexity of our system, political differences and a variety of other reasons.    

In the 1960s, President Lyndon B. Johnson had a vision for health reform in the United States where health insurance for the aged and poor would be available to those who needed it.  President Johnson was not the first president to try and push health reform.  Presidents Franklin Roosevelt and Harry S. Truman made attempts for the United States to have national health insurance but failed.  When President Johnson was elected, he made healthcare his top priority under his Great Society Programs which eventually resulted in Title 18 (Medicare) and Title 19 (Medicaid) of the amended Social Security Act of 1965.  On July 30th, 1965, President Lyndon Johnson signed Medicare and Medicaid into law at the Harry S. Truman Library with President Truman, the first recipient of Medicare insurance, by his side.  

Fast forward 45 years in 2008, only days after President Barack Obama was elected president, then-Senator Max Baucus of Montana released a report titled Call to Action: Health Reform 2009. The report advocated for meaningful health reform legislation that would achieve healthcare insurance coverage for every American while simultaneously addressing many of the underlying problems, such as access, quality, and outcomes, that plagued the American Healthcare System.  Senator Baucus’ report includes many features and is considered to be the foundation for what would be the Patient Protection and Affordable Care Act (ACA) of 2010. 

Healthcare delivery today still involves care at hospitals which house some of the best medical care and technology medicine has to offer.  However, the days of freestanding hospitals are becoming a thing of the past as large organizations become the predominant force in American Healthcare.  Managed care organizations exist with the goal of controlling rising costs and integrated delivery systems are becoming commonplace where inpatient care, surgical services home healthcare and a variety of medical services can be offered in a “one-stop shopping” type of setting. 

Healthcare in the United States has come a long way since Benjamin Franklin’s Pennsylvania House first opened its doors.  The U.S. Healthcare system still continues to evolve and we have seen that with the migration of inpatient to outpatient care, medical schools in the United States are now considered the best in the world, and legislation such as the ACA has provided healthcare insurance to millions of Americans who previously did not have coverage.