Chapter 3

Educational Reform

-Advances in medical science necessitated the reform of medical education. -Around 1870, medical schools began affiliating with universities. -Harvard revolutionized medical education, adopting the European model. -The academic year went from 4 to 9 months. -Medical instruction went from 2 to 3 years. -Labs and clinical courses such as chemistry, physiology, anatomy, and pathology were added. -Johns Hopkins University opened in 1893: A college degree was an entrance requirement. -Medical training became a graduate program. -Residency training was added. -The Flexner Report pointed to widespread inconsistencies in medical education. -Council on Medical Education created by the -AMA: Accreditation of medical schools

Creation of Medicaid and Medicare

-Before 1965, private health insurance was the only widely available source of payment for health care. >>It was available primarily to middle-class working people and their families. >>A three-part program was adopted to serve two distinct populations: Medicare Parts A and B and Medicaid. -Medicare Part A was designed to use Social Security funds to finance hospital care. -Medicare Part B was designed to cover physicians' services through government-subsidized insurance. >>The elderly would pay part of the premiums. -Although adopted together, Medicare and Medicaid reflected sharply different traditions. -Medicare was upheld by broad grassroots support and, being attached to Social Security, had no class distinction. -Medicaid benefits vary from state to state. -It is means-tested and confines eligibility to those below a certain income level. -Medicare has uniform national standards for eligibility and benefits. -It covers anyone over the age of 65. -In 1972, the program was expanded to include the disabled on Social Security and those with ESRD, regardless of age. -The Medicare and Medicaid programs are financed by the government. -Beneficiaries receive health care services mostly from private hospitals, physicians, and other providers.

MediCARE

-Covers all elderly persons, non-elderly disabled persons on Social Security, and non-elderly persons with end-stage renal disease -No income/means test -No class distinction -Part A for hospitalization and short term nursing home stay -Part B for physician and other outpatient services -Nationally uniform federal program -Title 18 of the Social Security Act -Part A financed through a payroll tax paid by employees, employers, and the self-employed -Part B subsidized through general taxes, but the participants pay part of the premium cost

MedicAID

-Covers only the very poor -Income criteria established by states -Public welfare -All services are covered under one program -Program varies from state to state -Title 19 of the Social Security Act -Financed by the states, with matching funds from the federal government according to each state's per capita income

Major Forces of Change in the US Health Care Delivery

-Cultural Beliefs -Social Changes -Tech Advances -Economic Constraints -Political Opportunism -Ecological Forces

Health care's evolution has followed time periods:

-Preindustrial era -Postindustrial era -Corporate era -Era of health care reform (still in its infancy)

Pre-Industrial Era: Medical Institutions

-Deplorable sanitation and poor ventilation -More dangerous to receive care in a hospital than at home -Almshouses (poorhouses) were run by the local government. -Hospitals were few and had deplorable sanitary conditions and poor ventilation. -State governments operated asylums for patients with untreatable, chronic mental illness. -Pesthouses were operated to isolate people. -Dispensaries were staffed by medical students or apprentices.

Pre-Industrial Era: Medical Practice

-Did not require the rigorous course of study, clinical practice, residency training, board exams and licensing -Physicians relied on their five senses -Physicians were either trained or untrained -Medicine was a trade without today's prestige. -It did not require a rigorous course of study, clinical practice, licensing, etc. Anyone, trained or untrained, could practice as a physician (e.g., barbers did bloodletting). -The clergy often combined medical services and religious duties. -Many physicians had a second occupation because income from medical practice alone was inadequate to support a family.

Employer-Based Health Insurance

-During World War II, employees accepted employer-paid health insurance to compensate for the loss of raises. -The U.S. Supreme Court ruled in 1948 that employee benefits were a legitimate part of union-management negotiations. -In 1954, Congress made employer-provided health coverage nontaxable. >>This was equivalent to getting more salary without having to pay taxes.

Failure of National Health Insurance in the US

-Failed to get any early footing because of labor and political stability in the US -A decentralized American system gave the US federal government little direct control over social policy -German social insurance was denounced during WWI. Since then, socialized medicine has been used as a synonym for national health insurance -AMA opposed national health care initiatives -Middle Class Americans have traditional beliefs and values that are consistent with capitalism, self-determination, and distrust of big government -Middle Class Americans have been averse to higher taxes to pay for the increased cost of a national health care program

U.S. health care is mainly a private industry but receives a large amount of

-Government finances health care mostly for the poor (Medicaid) and the elderly (Medicare). -The middle class must depend on private insurance.

Era of Health Care Reform

-Health care reform: major changes undertaken by the government to expand health insurance to the uninsured and regulate the financing and delivery of health care >>Numerous new regulations are made. >>The government's regulatory bureaucracy is expanded. >>The government controls various aspects of health care delivery.

Groundbreaking Medical Discoveries

-Horace Wells: discovery of anesthesia -Ignaz Semmelweis: aseptic technique -Louis Pasteur: germ theory of disease -Joseph Lister: father of antiseptic surgery -William Roentgen: discovery of x-rays -Alexander Fleming: discovered the antibacterial properties of penicillin

First Physician Plan and the Birth of Blue Shield

-In 1939, the California Medical Association started the first Blue Shield plan. -It was designed to pay physician fees. -By 1974, Blue Cross and Blue Shield merged. -Today they are a joint corporation and are in almost every state.

American Medical Association

-It helped galvanize the profession and protect the interest of physicians. -The concerted activities of physicians through the AMA is referred to as "organized medicine": -Gained power by controlling medical education -Supported states in establishing medical licensing laws -Discouraged employment of physicians by hospitals and insurance companies

Post-Industrial Era: Medical Services

-Late 19th Century -Urbanization -Scientific discoveries and their applications in medicine -Medical education reform -Power and prestige pf physicians -Organized medicine -Hospitals became true medical care institutions -Growth of private health insurance -Creation of MediCARE and MedicAID -Medical profession -American Medical Association -Educational reform -Development of hospitals

U.S. Health Care Today

-Main challenge: how to provide health care to all Americans while maintaining certain quality standards at an affordable cost -The ACA falls well short of providing affordable care to all Americans. -Medical corporatization has increased under the ACA: Accountable Care Organizations and Changes in payment methods have increased consolidation among providers.

Corporatization

-Medical care has become the domain of large corporations. -Managed care has become the primary vehicle for insurance and delivery. >>Consolidation of purchasing power -Integrated delivery systems -Physicians have consolidated into larger group practices and hospital partnerships.

Pre-Industrial Era

-Middle of the 18th Century until the latter part of the 19th century -Medical Training and education were not grounded in science -Primitive medical procedures were practiced -Intense competition existed because any tradesman could practice medicine -People relied on family members, neighbors, and publications for domestic remedies -Physician's fees were paid out of personal funds -Free Market -Few hospitals and in the big city -Hospitals had poor sanitation and unskilled staff -Almshouses (Poorhouses) served as destitute and disruptive elements of society and provided some basic nursing care -State governments operated asylums for patients with untreated, chronic mental illness -Pesthouses quarantined people with contagious diseases -Dispensaries delivered outpatient charity care in urban areas

The Affordable Care Act

-Most sweeping reform since Medicare and Medicaid -The law was passed by the Democratic majority in Congress. -The controversial law triggered lawsuits. -The U.S. Supreme Court upheld the constitutionality of the law but left the option of expanding Medicaid to each state. -The Supreme Court ruled that the ACA violated the Religious Freedom Restoration Act of 1993 in the case of privately held corporations. -The Supreme Court ruled that federal subsidies for the purchase of health insurance could not be restricted if a state did not establish its own exchange to sell health insurance.

Pre-Industrial Era: Medical Training

-Poorly trained -Education lacking in science -Until about 1870, medical training was largely received through an individual apprenticeship with a practicing physician rather than through a university. -It was a two-year doctor of medicine degree. -There were only about 42 such schools in 1850. -To train a larger number of students than was possible through apprenticeship, mainly out of economic necessity, American physicians began opening medical schools.Medical training -Medical practice -Medical institutions

History of Health Insurance

-Private health insurance is also called "voluntary health insurance." -Publicly financed Medicare and Medicaid were created to meet the medical needs of the elderly and the poor, respectively. -Workers' compensation -Rise of private health insurance -First hospital plan and the birth of Blue Cross -First physician plan and the birth of Blue Shield -Employer-based health insurance -Failure of national health care proposals -Creation of Medicaid and Medicare

Rise of Private Health Insurance

-Private insurance began as a form of disability coverage that provided income during temporary disability due to bodily injury or illness. -During the 1900s: Medical treatments and hospital care advanced, but medical care also became more expensive; People could not predict their future needs for medical care or its cost.

Corporate Era

-Started around 1970 and into the 21st Century -Corporatization -Information Revolution -Globalization

Information Revolution

-Telemedicine >>Integration of telecommunication systems into distant care giving -E-health >>Information and services over the Internet >>Empowered consumers

Hospital Plan and Birth of Blue Cross

-The Great Depression made hospitals economically unstable. -Individuals faced the loss of income from illness and the debt of high health care costs. -In 1929, Justin Kimball began a hospital insurance plan for teachers at Baylor University Hospital in Dallas, Texas. It became the model for Blue Cross plans around the country. -The AHA supported group hospital plans and coordinated them into a Blue Cross network.

Development of Hospitals

-The growth of hospitals came to symbolize the institutionalization of health care. -Advancements in medical science created the need to centralize expensive facilities and equipment in an institution. -Hospitals and physicians depended on each other. -Professionalization of nursing improved hospital care.

Conclusion

-The health care industry in the United States evolved from a primitive, family-oriented craft to the largest industry. -The corporate era of medical care delivery is characterized by large corporations, the information revolution, and globalization. -The era of health care reform was inaugurated by the Affordable Care Act of 2010. However, the law fails to provide affordable coverage to millions, even though the number of uninsured has declined.

Medical Profession

-Urbanization: Office-based practice began to replace house calls. -Medicine became driven by science and technology, outside the domain of laypeople. -Groundbreaking medical discoveries further legitimized the medical profession. -Bias toward specialization in medical practice -Increased cost of medical care

Globalization

-Various cross-border activities (information exchange, goods and services, interdependence of economies) >>Cross-country telemedicine >>Receiving health care abroad (medical tourism) >>Foreign direct investment in health care enterprises >>Migration of health professionals

Workers' Compensation

-Was the first broad-coverage health insurance in the United States -Was originally designed to make cash payments to workers for wages lost because of job-related injuries and disease -Later became compensation for medical expenses, and death benefits for survivors were added -Was a trial balloon for the idea of government-sponsored health insurance

History of Health Insurance

-Worker's Compensation -Emergence and Rise of Private Health Insurance -First Hospital Plan and the Birth of Blue Cross -First Physician Plan and the Birth of Blue Shield -Employment Based Health Insurance -Failure of National Health Insurance in the US -Creation of MediCARE and MedicAID

Health Care Reform

Major changes undertaken by the government to expand health insurance to the uninsured and regulate the financing and delivery of health care