Dr. Inrig's Presentation

Health System Reform in Health System Reform in American HistoryAmerican History

Stephen Inrig, PhDStephen Inrig, PhDAssistant Professor (Medical History)Assistant Professor (Medical History)Division of Ethics & Health PolicyDivision of Ethics & Health PolicyDepartment of Clinical SciencesDepartment of Clinical SciencesUT Southwestern Medical CenterUT Southwestern Medical Center5323 Harry Hines Blvd. 5323 Harry Hines Blvd. Dallas, TX 75390-9070Dallas, TX [email protected]@utsouthwestern.edu

Health System Reform in American HistoryHealth System Reform in American History

Pre-20Pre-20thth Century Century• Hospitals for criminals/indigent/poor peopleHospitals for criminals/indigent/poor people• Medicine based on physician careMedicine based on physician care• First US intervention in healthcare = 1798First US intervention in healthcare = 1798

End of 1800sEnd of 1800s• First nationalized health insurance – First nationalized health insurance –

Germany 1883. Germany 1883. • Medical progress (Germ theory/science-Medical progress (Germ theory/science-

based medicine) based medicine) • Science-based public healthScience-based public health


Early Efforts at Early Efforts at Healthcare Healthcare Reform Reform (1910s)(1910s)

• Payment = private Payment = private affair between patient affair between patient and doctorand doctor

• In the 1910s, initial In the 1910s, initial push was for “sickness push was for “sickness insurance” tied to insurance” tied to industry jobs.industry jobs.

• Reformers Reformers concentrated on state-concentrated on state-based systems of based systems of compulsory insurance.compulsory insurance.


Early Efforts at Early Efforts at Healthcare Reform Healthcare Reform (1910s – 1920s)(1910s – 1920s)• By 1920, “compulsory By 1920, “compulsory

health insurance” health insurance” efforts 15 states have efforts 15 states have largely diedlargely died

• AMA formally declares AMA formally declares its opposition.its opposition.

• ““Socialized medicine” Socialized medicine” becomes the rallying becomes the rallying cry of the opposition. cry of the opposition.


Health Care reform Health Care reform and the Depression and the Depression (1920s – 1930s)(1920s – 1930s)

• Committee on Committee on Economic Security can’t Economic Security can’t get health insurance in get health insurance in 1935 SSA.1935 SSA.

• Technical Committee on Technical Committee on Medical Care pushes a Medical Care pushes a second time for national second time for national health insurance in health insurance in 19381938

• Southern Democrats & Southern Democrats & Republicans New Deal Republicans New Deal social reforms.social reforms.


The emergence of The emergence of partial solutions partial solutions (1920s – 1930s)(1920s – 1930s)

• In the 1920s, the In the 1920s, the Committee on the Costs Committee on the Costs of Medical Care, proposed of Medical Care, proposed group medicine and group medicine and voluntary insurance.voluntary insurance.

• Hospital insuranceHospital insurance• Group medicine/medical Group medicine/medical

insuranceinsurance• Impact of WWII on health Impact of WWII on health

insuranceinsurance


Period of medical Period of medical expansion (1940s – expansion (1940s – 1950s)1950s)

• Increased medical Increased medical specializationspecialization

• Increased hospital Increased hospital use and constructionuse and construction

• Increased medical Increased medical researchresearch• Increased medical Increased medical regulationregulation


Changing funding Changing funding mechanisms (1950s – mechanisms (1950s – 1960s)1960s)

• Failed Truman Effort Failed Truman Effort (1948/9)(1948/9)

• 1949 Court rules health 1949 Court rules health insurance benefits = insurance benefits = subject for collective subject for collective bargainingbargaining

• 1954 – Congress 1954 – Congress determines health determines health insurance non-taxableinsurance non-taxable

• Elderly CareElderly Care


Johnson, Kennedy, and the rise of Johnson, Kennedy, and the rise of Medicare/Medicaid (1965 – 1966)Medicare/Medicaid (1965 – 1966)

MedicareMedicare

MedicaidMedicaid


Nixon/Kennedy & Nixon/Kennedy & Social/Health Security Social/Health Security debate (1971 – 1974)debate (1971 – 1974)

• Kennedy/Griffiths/Corman Kennedy/Griffiths/Corman Health Security Act Health Security Act

• Nixon Comprehensive Health Nixon Comprehensive Health Insurance Plan (CHIP)Insurance Plan (CHIP)

• Long-Ribicoff plan Long-Ribicoff plan • Kennedy/Mill Compromise Kennedy/Mill Compromise • HMO Act (1973)HMO Act (1973)


The Reagan-Era Pendulum The Reagan-Era Pendulum (1980s)(1980s)

Pay freezes and Pay freezes and shrinking reimbursementsshrinking reimbursements

COBRA/EMTALA (1986)COBRA/EMTALA (1986)

Medicare Catastrophic Medicare Catastrophic Coverage Act (1988)Coverage Act (1988)


The Clinton Plan (1993)The Clinton Plan (1993) Brief DetailsBrief Details Why it failedWhy it failed

Other issuesOther issues


The Bush Years (2003)The Bush Years (2003)• The Medicare Prescription Drug, The Medicare Prescription Drug,

Improvement, and Modernization Act Improvement, and Modernization Act (2003)(2003)


The Obama Years (2009 - 2010)The Obama Years (2009 - 2010)• Will we have a healthcare bill?Will we have a healthcare bill?

Infant Mortality RateInfant Mortality RateInfant deaths per 1,000 live births, International Comparison, 2004

2.8 2.8 3.1 3.2 3.3

4.4

5.3

6.8

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

Data: National and state—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2003, 2004, 2005, 2006, 2007a); international comparison—OECD Health Data 2007, Version 10/2007.



86

7773 72 69 67

0

25

50

75

100

GER AUS UK CAN NZ US

Medications Reviewed When Discharged from the Hospital, Among Sicker Medications Reviewed When Discharged from the Hospital, Among Sicker Adults, 2005Adults, 2005

Note: Indicator was not updated due to lack of data. Baseline figures from Scorecard 2006 are presented. AUS=Australia; CAN=Canada; GER=Germany; NZ=New Zealand; UK=United Kingdom; US=United States.Data: 2005 Commonwealth Fund International Health Policy Survey.



7681

88 8489 89

99 9788

97

109 106116 115 113

130134

128

115

65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110

0

50

100

150 1997/98 2002/03

* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.See report Appendix B for list of all conditions considered amenable to health care in the analysis.Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files (Nolte and McKee 2008).


Mortality Amenable to Health CareMortality Amenable to Health CareDeaths per 100,000 population*

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