Introduction
The organization of health care in the United States has undergone major changes in recent years. In this chapter, the historical background is presented, after which the organization of health care as it exists in 2006 is outlined.
Historical Background
Health care in the United States was initially provided by generalist physicians. During the colonial era, they graduated largely from the medical schools of Great Britain. By the time of the Revolutionary War (1776), however, some physicians in the United States developed expertise in certain areas and were considered specialists. Medical schools were established in the United States along with the earliest universities and tended to follow the Scottish model. Under the Constitution, regulation of medical practice in the United States is relegated to the individual states. As a result, each state has its own licensing authority. During the 19th century, the quality of training and care varied widely, and fraudulent claims to medical training were frequently made. This was particularly a problem in rural areas of the western states.
By the time of the Civil War (1861), specialization in neurology had developed, and some of the earliest research in neurologic disease was done at that time. The specialties of neurology and psychiatry were closely intertwined from the earliest days of the medical system.
At the beginning of the 20th century, under the aegis of a charitable foundation, a study of medical education in the United States was carried out (the Flexner report), and a revolution occurred. A national accreditation authority for medical schools was established, and medical schools were reorganized more along the lines of the German system. Training in basic science was required of all students, and organized clinical training began. Still, up to the beginning of World War II (1939), the overwhelming majority of physicians were in primary care, and specialty care was available only in major cities and in association with university schools of medicine.
The end of World War II, the creation of the GI Bill of Rights, and the establishment of federal subsidies for medical insurance, research, and education produced a second revolution. Large numbers of physicians were trained, many more medical schools were established, and specialty training in the form of residencies became the norm. State licensing authorities no longer permitted physicians to practice after only a single year of postgraduate training (internship), and formal residencies and accreditation boards were created in all specialties, including family practice.
Large numbers of dollars flowed into the health care system as health insurance became a fringe benefit provided by nearly all large employers. Health insurance was readily available for purchase by individuals, and the federal government began subsidizing health care for the poor and elderly.
Levels of Care
Nonetheless, today, the United States, despite its enormous wealth, fails to provide for the basic health needs of a large part of its population. It has more levels of care than any other major industrialized country.
Level 1: Provisions for the Very Poor, Whether or Not They Are Homeless
The very poor have no money and no health insurance. Historically, they depended on charitable acts of individual physicians. As practices became more highly organized, and the poor became more concentrated in inner cities, finding access to charity care became increasingly more difficult. The federal government provided large amounts of money to hospitals for capital expansion and modernization under the Hill-Burton Act of 1946. A subsequent law required any hospital that received Hill-Burton funds to provide emergency care to all coming to its emergency department, whether or not they could pay. This was the final safety net, but provided only for the most obvious emergencies. However, the educational needs of physicians in training and the sense of local responsibility on the part of cities and counties has led to a system of county hospitals with outpatient facilities of varying completeness. Some of these are now being closed because of fiscal constraints.
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