The below essay summarizes American healthcare history from 1850 to 2016. It divides it into five eras as was assigned, and each era comes with a quote from Paul Starr's The Social Transformation of American Medicine and Jonathan Cohn's Sick. Each era also has a defining discovery, and a defining non-healthcare event that changed the healthcare system.
Marc Novicoff
Healthcare in American Society
November 22nd, 2021
Discoveries, Exogenous Shocks, and the Seeking of Status: The American Healthcare System 1850-2016
America in 2016 was a very different country than America in 1850, and the healthcare system has the scars to show it. But although looking back 166 years makes the changes look blurred and quick, the true story of America and its healthcare system is one of slow, incremental change. Though America is young, those 166 years featured far more stability in America than in any other place on Earth, and with no real threat of total collapse, and thousands of miles of sea separating it from the rest of the developed world, America had the chance to move slowly, with most changes spurred from the inside. Its healthcare system chugged along, with each era bringing not a whole new system, but rather a different mood, first of skepticism, then deference, then downfall and expansion, then anger, and finally, hope. With each mood came changes to the system that reflected it, some of these changes planned by the government, and others arising from a private sector desperate to squeeze more money from meeting people’s desires. We begin the story in 1850, as the medical activism of early America gave way to medical skepticism.
1850-1881: The Era of Sectarianism; Discovery: Nursing; American Event: Civil War, Leadup
Starr: “The society was not just pluralist, but ‘pluralizing’: It created new divisions as well as incorporating traditional ones” (95).
Cohn: “What really needs to be changed is the whole health care situation” (165).
The history of American healthcare from 1850-1881 can be characterized by the struggle of orthodox physicians to prove themselves as a valuable and respectable class, having never thus far been effective at healing people. Physicians’ lack of efficacy was partly to blame for their lower-middle-class position in society, not just in terms of income, but in terms of how the educated elite felt towards them. But class and status were just the beginning of physicians’ problems—there was also a problem of basic legitimacy: people were not sure physicians trained in the orthodoxy knew what they were doing. That fact, combined with a nation at its least united, spelled sectarianism.
Beyond the simple fact that physicians were not good at healing people, another thing that made them low-status and untrustworthy was the scam-like, unprofessional system of medical education that had emerged during this era. Most medical schools had opened for the purposes of profit and credentialism, making the curriculum short and easy, and refusing to discriminate, so they could take money from all types of people.
Skeptical of the prevailing therapeutics and the doctors that administered them, patients sought out alternative ways of maintaining wellness and treating disease. The first challenge to medical orthodoxy came from Samuel Thomson’s followers, who believed temperature and purging were key to treating disease, offering laxative and vomit-inducing herbs. This movement died out in the 1850s, giving hope to a medical establishment desperate to establish their position as the officially recognized healers. But this hope did not last long, as the medical orthodoxy quickly faced challenges from eclectic medicine, a school of botanist-medicinal thought based mostly in the frontier, and homeopathy, a movement popular with elites, devoted to giving tiny doses of medication, which often worked decently well because the doses were too small to do any harm. Both of these movements, in addition to hydropathy, abstinence, over-chewing, and over-pooping were extremely common up until at least the 1890s, despite orthodox doctors’ trying quite hard to marginalize them, including by founding the AMA to distinguish themselves.
One major reason patients were so fragmented in their demands of doctors was because the country itself was so fragmented. In the leadup to the Civil War, unity was severely lacking in American society—there were conflicts in the north vs. the south; the farming elite vs. the industrial elite; the rural poor vs. the urban poor, and most potently, there was racial tension. Americans were profoundly disjointed and tense, and the Republic was unstable, with no unified ideology or purpose; it was a perfect time for a previously respected industry like medicine to be disrupted and made to face the open competition of quacks, hydropaths and homeopaths.
However, the main reason patients were so skeptical of orthodox medicine was because it did not work. Orthodox physicians usually just induced endless amounts of useless pain on their patients, and then accidentally gave them an infection, often killing them. Sure, we still have examples of mistakes made by doctors—Complications by Gawande is full of them—and we also have examples of brutalism with unclear efficacy; Wit is about a modern struggle with such cancer treatment. But in this first era, the mistakes were not on the margins; rather, they were glaring by today’s standards. Basic hygiene was lacking, ready to be disrupted by a nurse named Florence Nightingale. She was known for her angelic care as a nurse in Crimean war camps in the 1850s, and her attention to hygiene made mortality rates fall precipitously wherever she went. The implementation of basic hygienic standards in hospitals by the end of this era allowed medicine to approach the point of being net-helpful to patients, rather than net-hurtful.
1881-1927: The Era of Deference, Discovery: Tuberculosis bacterium, Event: McKinley’s death
Starr: “The state, which had been indifferent to physicians’ claims since the Jacksonian era, finally embraced the profession’s definition of a legitimate practitioner” (81).
Cohn: “Still, she was pleased to have gotten such attentive medical care” (29).
From 1881-1927, new discoveries in science and medicine allowed physicians to achieve an unprecedented level of efficacy, and that led the American people to respect and revere them and the science that enabled them. In addition, savvy doctors created different types of corporate-like enterprises in the healthcare industry, but the AMA—equipped with the boogeymen from WWI—successfully staved off corporate and governmental control, at least for now.
In the late 19th century, the largest scientific discoveries were those surrounding germ theory. The most notable was Koch’s discovery of the bacterium responsible for tuberculosis (TB), one of the deadliest and widespread diseases in America. Germ theory displaced the theory that disease was caused by noxious miasmas, and Koch’s discovery proved the use of germ theory, building on discoveries like Pasteur’s bacterial fermentation and Lister’s carbolic acid sterilization. The achievements of these scientists rendered medical care both more accurate and more efficacious.
The increasing efficacy of medicine naturally earned doctors and science greater respect, status, and deference, all of which became a staple of the Progressive Era, which cohered with Teddy Roosevelt’s assuming the presidency after McKinley’s assassination. The public and their representatives’ respect for medicine could be felt in the 1906 Pure Food and Drug Act, which dictated that drugs should not meet whatever the imagination of a patient was (as in the sectarian era), but rather be tightly regulated as to ensure efficacy, given the legitimate complexity that drugs had reached. State legislatures also began to regulate medicine and credential doctors in this era through licensing and medical school curricular requirements.
Physicians, though hesitant at first, welcomed this regulation, knowing it would bring them the social status and class position they had previously only dreamed of. The AMA even decided to take matters into their own hands to project professionalism by asking the Carnegie Foundation to commission the 1911 Flexner report, a scathing review of medical schools and their standards, leading to the closure of 25% of medical schools, the shrinking enrollment of many of the others, and the enrichment of the well-reviewed schools. A new model of medical education emerged, exemplified by Johns Hopkins, where already-college-educated rich white men would be subject to two years of rigorous courses and then two years of clinical practice before graduating and getting an internship and then perhaps a residency after that.
The residencies were created for an emerging, well-respected, soon-to-be highly paid class of doctors called specialists, who had virtually no relationships with patients, and were instead experts at a very particular disease or part of the body. With the growing respect that medicine was given, the field was given license to specialize more and more, a change that did not fade with the end of the Progressive Era, and the cause of a problem—lack of primary care—that does not exist, or is not close to the same degree, in other developed countries.
This era was also characterized by attempts to make medicine more accessible, coherent, and less shock-inducing. Starting with the Mayo Clinic, private group practices sprung up to provide more unified and coherent care. Several large corporations including rail and steel companies entered fixed contracts with medical providers to treat the employees, since large employers of laborers profit from their employees’ good health. In addition, fraternal orders and lodges, popular associations of working men, began to pay doctors a fixed amount per member per year—not exactly the health insurance of today, but a basic form of it. The Mayo Clinic did not seem so bad to organized physicians’ interests, but contract medicine served a legitimately frightening threat to their autonomy—doctors would no longer have total freedom over what services they offered and provided, and how much they charged for them. But during World War I, two enemies materialized who conveniently fit perfectly for the AMA’s argument against more health insurance: the Germans and the Bolsheviks, both of whom guaranteed health insurance to their citizens. The AMA, during the latter half of this era, successfully rhetorically tied more organized, corporate, or national healthcare schemes with Germany and/or Communism.
But WWI wasn’t all good for the medical establishment. It also brought the end of the Progressive Era’s deference to science and medicine, in part due to seeing that science was not just about healing the sick, but also could be used to gas people to death in droves, as was first done in World War I. The Russian Revolution, though, brought the First Red Scare to America, giving libertarian-inclined Americans (and the AMA) an easy and persuasive boogeyman, ushering in an unregulated and “Roaring” 1920s, the consequences of which caused profound shifts to American society during and after the Great Depression.
1928-1959: The Fall and Rise, Discovery: Penicillin, Event: WWII
Starr: “A family’s chances for insurance depended on its income and the employment situation of the main earner” (334).
Cohn: “The essential ingredient for this relationship was the nation’s sustained postwar prosperity, in which [a company] and, ultimately, its workers shared” (97).
The Roaring 20s gave way to the Great Depression, a tragic economic shock that made poverty and unemployment rates skyrocket. The Great Depression also gave the government the political mandate to expand rapidly, and President Franklin Roosevelt presided over this expansion with a charismatic touch, though never providing universal health insurance. The Great Depression gave way to World War II, which—though it cost hundreds of thousands of American lives—also turned America into the economic and geopolitical superpower it has remained ever since. Then came the postwar era, which saw the creation of a vast American middle class, one that for the first time would be insured largely by their employers so that they could receive the new medical discoveries made in the years prior.
The under-regulation of the economy and under-provision of public goods that occurred during the 20s became profoundly obvious to the public when the economy crumbled and 25% of workers became unemployed and therefore impoverished, with the assistance essentially only of charities. The immense suffering and the magnitude of its increase during the Depression made glaringly obvious to citizens and politicians that greater social support programs must be pursued, and Franklin Roosevelt was elected in 1932 to do just that. In his first term, he made great strides in this regard, signing the Social Security Act, which encouraged states to create unemployment insurance (UI), in addition to creating Social Security (SS), which awarded monthly checks to the vast majority of elderly people. Roosevelt considered adding national health insurance into his plans, but his fear that it would threaten his other programs, in addition to tremendous lobbying from the AMA, killed that idea. The AMA’s lobbying next killed Truman’s idea for a welfare fund to pay working people’s medical bills.
During World War II, large numbers of employers began to offer health insurance as a way to give higher compensation during wage freezes. Though the AMA had previously been opposed to employer-based health insurance, the physicians’ lobby warmed up to the idea after having to fight tooth and nail to prevent Roosevelt and Truman from implementing national health insurance, which they feared far more. So, when Eisenhower insisted that more Americans be insured, he made employer-tied health insurance tax deductible and subject to collective bargaining, pleasing the AMA by dropping national health insurance as an idea, pleasing employers by making some of their compensation untaxable, and pleasing many unions who enjoyed a popularity boost from being able to win additional benefits for their members.
In addition to employer-tied health insurance, World War II also saw the employment of major medical advancements, such as antibiotics (namely penicillin, discovered in 1928, but not widely used before the war), and advanced surgery techniques. Not only did this make World War II safer than it would have been otherwise, these discoveries were soon employed outside the confines of war, making medical care more efficacious and thus more desirable for people.
Insurers filled the demand induced by the combination of Ike’s compromise and the advent of more advanced medicine. Blue Cross was started at Baylor University to guarantee teachers hospital care, and Blue Shield was started in the Pacific Northwest for lumber workers to pay capitations in exchange for doctors’ visits. Prepaid group practices, starting with Kaiser, also arose, where companies would pay upfront for care at facilities controlled by the prepaid group practice, with the companies’ employees only allowed to seek care at those facilities.
So, as the economy boomed in the postwar era, the middle class grew and solidified, protected from income shocks by UI, protected from having to save for retirement by SS, and usually insured by their employers to take advantage of the increasing efficacy of care.
1960-2007: Progress then Problems, Discovery: CABG, Event: JFK’s Death
Starr: “Enormous increases in costs seemed ever more certain; corresponding improvements in health ever more doubtful.” (379)
Cohn: “The total for her two-night stay came to $11,000” (143).
The booming postwar economy made most of America richer, and Eisenhower’s deal made most Americans insured by their employers. The two biggest groups left uninsured were the elderly (insuring them would be too costly) and the poor, and President Lyndon Johnson was able to insure them using the government, equipped with the popular mandate that came after his predecessor John Kennedy’s assassination. But America’s new vast wealth, which throughout this era was never seriously threatened by a massive recession, also enabled a new type of bad health— “lifestyle” disease, not caused by genetics or germs, but rather poor decision-making, leading to increasing deaths caused by underlying problems like smoking and obesity. The combination of poor health, steadily advancing medicinal practices (including some which dealt with “lifestyle” diseases like the new CABG), and the fact that nobody paid for their own healthcare anymore led to gigantic increases in health spending, which then led people to wonder if healthcare was being overutilized and if even more corporate schemes that do not charge fee-for-service could assist with this. To some extent, these schemes reigned in spending, but efforts to insure greater segments of the population failed miserably after Johnson and before Obama.
The big reform of this era took place at the start of it. President Kennedy fought hard for the creation of a health insurance program for the elderly, but Southern Democrats and Republicans successfully stood in the way. When Kennedy was killed in 1963, now-President Johnson argued that to stand in the way of his plan to give health insurance to the elderly was to spit on the grave of the popular President Kennedy. Johnson also snuck a provision in the bill to insure the poor (Medicaid), but this did not upset moneyed interests very much because the poor would usually just forgo care or declare bankruptcy, so the government’s insuring them gave providers more money and did not take away customers of insurers. So, by the end of 1965, the vast majority of elderly, impoverished, and working people had health insurance.
But one reason Medicaid was an easy sell was because nobody realized how much healthcare costs would skyrocket in the ensuing years. As America settled into being a rich country with a huge middle class, something weird happened: not all aspects of health went up—diseases like diabetes, heart disease, and lung cancer went up quite a bit due to voluntary actions by Americans, raising healthcare costs, especially thanks to new surgeries to treat these diseases like bypass surgery (CABG). But the Americans who made these unwise decisions did not pay for those health services, as more than 80% of people had health insurance. And since doctors knew that the entity paying the bills was not their patient, they began to utilize more and more services, taking advantage of new technologies in surgery like CABG and organ transplants, and in imaging, like the MRI machine. Doctors’ specialization also ticked up, in part because medicine was genuinely becoming more complex, and partly because those doctors were greedy.
Nixon attempted to tackle the rising costs problem, while also guaranteeing health insurance to all working people through an employer mandate. He succeeded in the first goal, passing the HMO Act, providing federal support for the creation of more health maintenance organizations (HMOs), previously called prepaid group practices, and mandating that large employers offered HMO plans for their employees, which save on costs by making them upfront, offering doctors’ no incentive to overutilize. But before he could work on instituting a full employer mandate of health insurance, Watergate happened, and Nixon was forced to resign.
After Nixon, the population’s perception of the healthcare industry only went down as costs continued to skyrocket. The 70s were a time for the expansion of the rights demanded by citizens, from merely negative rights to positive rights (like to healthcare), and to group rights, like patients’ rights and women’s rights. People demanded more and more from the healthcare system, but did not want to see more and more money sucked out of their wallets for it. This discontent was rather constant through the 1990s, especially with the continued expansion of “managed care,” which was very unpopular with both doctors and patients for its rules about who could give care to who and how much could be charged. Pres. Clinton tried to guarantee health insurance, this time through what he called “managed competition,” where insurers would compete in a regulated market on cost and access. But his idea failed when it was seen as too ambitious by some and not ambitious enough by others, and the nail entered the coffin when the Black Hawk Down incident forced him to focus on foreign affairs, and in 1994, Clinton lost the House and Senate, which he would never regain. So, as the millennium turned, the healthcare industry stayed in low regard, and the percentage of Americans uninsured had only increased since the 70s, though more insured Americans were insured through preferred provider organizations (PPOs) with utilization management (UM), which had far looser restrictions about which doctors you could see and were thus a bit more popular.
2008-2016: Hope, Discovery: Advancements in Cancer Treatment, Event: Obama’s re-election
Starr: “By 2009, however, there was a new opening for reform” (471).
Cohn: “Still, even in the bleakest corners of South Central Los Angeles, some families clung to one precious asset: hope” (169).
With 9/11, Americans shifted their priorities to national security and Pres. Bush, unambitious in domestic policy, persuaded Americans he would keep them safe. But, when the recession of 2008 struck, Americans sought a new direction, and elected Obama, the first black president, whose most famous campaign image was a portrait of him above the word “HOPE” and whose surprising success in the primary could be traced back to not just Hillary Clinton’s lasting unlikability, but to Obama’s powerful oration, which allowed him to skate by McCain, who had no chance anyway given the state of the economy. On top of Obama’s win, his party secured a bigger majority of the Senate than we have seen since, and Obama used it to pass his healthcare plan, which nearly halved the uninsured share of the population. It did this through several mechanisms: an individual mandate (helped by subsidies and an exchange), an employer mandate, widening Medicaid eligibility, and a rule preventing insurers from rejecting customers based on their pre-existing conditions. In addition to insuring more people, the evidence appears to be that Obamacare seriously curbed healthcare inflation, probably through lower Medicare reimbursement rates. Lower rates of healthcare inflation, more people insured, and more so by PPOs gave people hope and ambition about government involvement in healthcare, and 2016 featured the most successful socialist presidential candidate in the history of America, whose number one platform item was Medicare-for-all-Americans.
New technologies also gave reason to have hope. Cancer treatment became more and more effective, rendering some cancers like prostate cancer essentially nonfatal and making child deaths from cancer far rarer. New research into stem cells gave people hope that almost any disease could be cured in theory, since the cells can morph into many different types of cells. Time will tell whether we were right to have high hopes in this era, but our faith in science seems well-founded, even if the pace and kind of scientific discovery we will achieve is unknown.
Conclusions
Above all, the history of health care in the United States of America, like much in American history, has been shaped by class politics. The class interests of doctors, specifically, explain much of the history of American healthcare. First, the AMA was formed to distinguish them as more professional than the homeopaths, and then soon after, the AMA lobbied through Carnegie and Flexner to shut down tons of medical schools, keeping women, minorities, and low-income folks from entering the profession for generations, in order to attain a professional image. Next, the AMA lobbied several times to prevent a universal health insurance plan from being created by the government, and since that succeeded many times over, they went further and lobbied to have no centralized control over doctors at all, especially not if it meant cutting healthcare costs, possibly threatening their position as rich by virtue of existing and without having to be particularly good at their job. Over and over again since the 19th century, organized physicians have pressured policymakers and the public into making sure doctors’ wages stay high, through whatever means possible, whether that be smaller medical school sizes, the prevention of universal health insurance, or through increased licensing laws. Perhaps there are some positive effects to the everlasting social climb doctors partake in—maybe they are more inclined to do a good job knowing that any positive performance will improve their profession’s perception and pay. But, overwhelmingly it seems to me, the effects of the ambitious nature of the medical profession have been negative, leading to easily fixable problems like the unnecessary “pre-med” requirements to get into medical school, and much bigger problems like rural lack of access to medicine, a shortage of primary care providers, inflated drug prices, and the need for a universal health insurance plan.
But doctors are not alone in having class interests, and the history of American healthcare is shaped by other groups’ class interests too. Another reason we do not have universal national health insurance is because union bosses, and many of their employees, wanted to have something to fight their employers on and win and assert themselves as a powerful class worthy of respect. A third reason we do not have universal health insurance is because rich people want to have the best care possible in the shortest amount of time, not to wait in line for society to allocate a doctor who is most likely to have average skills. And the main reason most people have health insurance at all is because of the powerful class interests of the vast expanding middle class right after WWII. And the reason HMOs gave way to PPOs in last 30 years is because the leverage of the working and middle class went up during the strong economy of the 90s and early 2000s. Even small contours of the healthcare system can be traced back to class interests. When I had an infected finger in need of gashing and draining while living in a rural town of 750 people, I was treated by a nurse practitioner, a ridiculous oxymoron of an occupation that exists because nurses’ class interests were too powerful to be completely overpowered by doctors’, but not so powerful as to make it take less than 8 years to prescribe me the pain drugs I could have used after the gashing.
America is always the battlefield of many class wars at once. Today’s politics are increasingly the battle between the professional-managerial class and urban poor on one side, and small business owners and rural poor on the other, but that alignment is totally different than the one we had thirty years ago, which itself was very different than the one we had thirty years before that. The healthcare system is no different; wars are being fought between doctors and nurses and patients and employers and insurers and pharmaceutical companies, and increasingly many of those actors are controlled by the same conglomerate—and still that doesn’t cause anything approximating a ceasefire. In 2020, a new class emerged in the healthcare industry, of public health bureaucrats who believe they can and should set policy for everyone to abide by, not merely give advice about whether to eat your steak undercooked or have that extra glass of red wine. Just a few months ago, the Supreme Court had to strike down an order from the CDC that had prevented any evictions anywhere in the country from occurring for months. And this class is not remotely close to being done asserting itself.
As America changes, there will always be new class wars to be fought, and those battles will always influence the American healthcare system.