5% in 1960 & 18% in 2019
P R O L O G U E
8 pages — 1 —
HUMAN DIGNITY FOR EVERYONE
“We are living in a time of unbearable dissonance:
between promise and performance;
between good politics and good policy;
between professed and practiced family values;
between racial creed and racial deed; between calls for community and
acts of rampant individualism and greed;
AND
between our capacity
to prevent and alleviate human deprivation and disease
and our political and spiritual will to do so.”
Marion Wright Edelman (1939 – 2020)
THE OLD ERA — BEFORE 1860
Before 1860, a person could remain healthy by avoiding three health conditions. The three health conditions most frequently leading to unstable HEALTH were: 1) poor nutrition, 2) a severe injury especially occurring during childhood or armed conflict, and 3) a contagious infection. Historically, contagious infections and violence have always been a constant threat, especially during childhood. Infection was most devastating when it occurred to women after childbirth. And, tuberculosis (“TB”) affected almost every independent person late in life.
If you survived poor nutrition, armed conflict, pregnancy, and contagious infections, you usually died from TB. It was called “consumption” because a person with TB suffered from profound weight loss. The weight loss occurred because a person with TB requires a very high level of energy to breathe and to control the infection.
Healthcare before 1860 was primarily the responsibility of a person’s Family, their Extended Family, and their Family Traditions. Cities, counties, and their hospitals, originally known as poor houses, cared for their community’s resident persons who did not have a Family or Extended Family. We now recognize these resident persons as “homeless.” In addition to the poor houses, there were religious communities that cared for persons without a Family by opening their own hospitals, the equivalent of nursing homes by modern-day standards. Eventually, a few of these institutions evolved to become hospitals, as we now know them.
THE PRE-ANTIBIOTIC ERA — 1860 to 1940
Between 1860 and 1940, major improvements occurred for sustaining a resident person’s HEALTH. Cities developed standards for food, water, and sewer sanitation. Public health departments improved their use of quarantine to control epidemic infections. Hospitals advanced their level of services as the knowledge of sanitation and anesthesia for surgery became widely accepted. In many states, special hospitals known as sanatoriums took care of people with TB. Each state passed laws to authorize the commitment of a person with TB to these state-sponsored hospitals, even against their will, for extended rest and nutrition. These laws established the legal precedent for other HEALTH-related conditions, such as cancer registries, mental health commitments, and contagious-disease investigations.
By 1920, medical schools and their associated teaching hospitals became more commonly integrated with a university. This connection improved the degree of precision within our nation’s healthcare for its research, diagnosis of disease, and the education of physicians. Slowly, the institutional commitment to quality healthcare began to develop. Hospitals and medical schools became accredited, and states began licensing physicians. The American College of Surgeons (a professional organization) initiated the original hospital accreditation process, and the early certification of physician specialties soon followed. The first entry into healthcare by the federal government occurred in 1906 when Congress established the Food and Drug Administration (FDA) within the Department of Agriculture.
Even with a Congressional revision in 1938, the FDA did not have a legally defined authority to fully regulate medications until 1962. During 1962, Congress adopted the Kefauver-Harris Amendment. The requirements for the scientific evidence of medication safety and effectiveness had become clear after the thalidomide disaster in Europe. The FDA refused to approve the drug in the USA primarily through the efforts of its staff pharmacologist, Frances Oldham Kelsey. The 1962 Amendment became a worldwide model for regulating the production and marketing of safe medications. — 3 —
During the OLD ERA before 1860, a physician would choose a location to open an office based on personal preference. By the end of the PRE-ANTIBIOTIC ERA in 1940, the decision process was mainly a business decision. With the obvious exception of a few large groups of physicians such as the Mayo Clinic, physicians were “in business” for themselves. Laws in some states required a physician to be self-employed. Many medical schools were dependent on these self-employed, volunteer faculty for their educational mission. Teaching at a medical school while in private practice was mutually beneficial for both the physician and the medical school.
THE ANTIBIOTIC ERA — 1940 – 1970
FINDING “THE CURE”
The production of Penicillin created a new level of “miraculous” precision for the benefits of healthcare. During World War II, Congress authorized a collaborative effort among pharmaceutical companies to develop and produce penicillin. It represented a temporary paradigm shift for the benefit of wounded soldiers. The introduction of the first true antibiotic, penicillin, led to its initial bedside use for the benefit of soldiers. Penicillin’s short testing and production cycle of ONE year represented a wartime heroic effort, an example of collaborative success that would be repeated during 2020 for the COVID-19 pandemic. The resultant boost in WWII military morale from the improved survival following war-related injuries may have contributed to the success of the allied victory in Europe.
For the next thirty years, the first antibiotic medications on their own fostered a national expectation that eventually every illness could be treated based on the antibiotic theory of disease and its cure within 10 days. For many physicians and their patients, it was only a matter of time until a simple cure would be found for every illness. This tradition within our nation’s healthcare continues even today as evidenced by the fund-raising goals of many non-profit institutions. Their fund-raising goals frequently use a variation of this logo: “Finding a CURE for (any illness).”
Amid all the illnesses possibly affecting a person, there are only a few that respond to a simple strategy for their cure. Admittedly, these can be spectacular. But the facts of the medication use are simple. The general expectation for the benefits of healthcare usually does not mirror the antibiotic model of an immediate cure by a single and safe, therapeutic intervention. As a result, many people have become discouraged because their expectation for “antibiotic-style” healthcare is so rarely possible.
Similarly, new hospitals, more doctors, the latest surgical robot, or the electronic medical record may not necessarily produce better Population Health. In response to these highly technical, very expensive and occasionally harmful adaptations, many citizens have become highly suspicious of modern healthcare. It is likely that the increasing use of ‘alternative’ forms of healthcare by many resident persons is a response to the misinterpreted expectations for the healthcare industry. In effect, the ‘alternative forms’ of healthcare represent the efforts of many resident persons to achieve a better sense of self-control over the needs of their own HEALTH.
HEALTH INSURANCE
Health insurance appeared increasingly after 1940, initially as an extension of the control by each state over its own insurance industry. Even though sporadic efforts by Unions to offer prepaid healthcare began around 1900, widespread health insurance eventually became increasingly available after World War II. To promote health insurance, the federal government defined health insurance as a business expense, rather than as income to the employee. This meant that the employee would not need to pay income tax on the benefit, and the employer could use the expense to reduce the company’s taxable income. At the same time, one or more Blue Cross and Blue Shield institutions developed locally in each state. The Blue Laws, of each state, sanctioned these non-profit institutions. Eventually, the combined “Blue” institutions formed a national clearinghouse to reconcile the benefits provided by the Blues to insured members for any healthcare they required while traveling away from their home state.
BIG BUSINESS
From 1940 through 1970, our nation’s healthcare evolved through unprecedented growth and consolidation of the economic interests within the healthcare industry. Pharmaceutical companies, medical equipment suppliers, national private insurance companies and medical schools, all developed a special economic self-interest in the affairs of our nation’s healthcare. Similarly, several smaller hospitals would consolidate in many communities producing locally larger healthcare institutions. Along with university-based medical schools, many of these consolidated hospitals have more than 300 beds. The economic impact on a community is substantial since these healthcare systems often represent the largest employer within a community. In many rural communities, a small critical-access hospital, or a nursing home are the largest employers in town. — 5 —
By collaborating with their associated teaching hospital after 1960, medical schools changed their teaching staff substantially from the volunteer, community-based physicians to full-time faculty. This transition coincided with options for improved financial support from the payers of HEALTH insurance. Eventually, the healthcare industry’s economic support became even more concentrated after Congress established Medicare and Medicaid in 1965.
Eventually, Medicare funding became especially important for medical schools as a means to pay for the training of specialists. In 2010, Medicare paid $8 Billion to medical schools for this training. By 2015, it was $18 Billion. Beginning in 2016, they began graduating so many medical students that some students might not be able to locate a specialty training, a residency, within the United States. The medical schools had increased their undergraduate classes without an increase in the financial support of the residency training programs within each State.
Finally, physicians became “employed” by either healthcare systems or group practices. Two surgeons in Fremont, Nebraska formed the first Professional Corporation within Nebraska in 1954 in order to qualify for social security. In 1958, the physicians-in-training associated with the hospitals run by New York City formed the first, and still operating, union for Physicians. Overall, there was widespread consolidation of the economic vested interests of physicians. These included the specialty institutions for certification, provider contracting institutions, and buyer groups. Increasingly, insurance companies applied actuarial principles to reimbursement practices. As a result, physicians who charged for special tests or for surgery had higher incomes, solely because their charges represented a relatively better level of actuarial stability.
THE POST-ANTIBIOTIC ERA — 1970 – 2010
IMMUNIZATION
The ANTIBIOTIC ERA ended as the technical complexity and the related cost of healthcare began to advance very quickly after 1969. This transition began at the same time that an immunization vaccine for measles first became available. Measles was the last widespread, very dangerous childhood contagious disease to come under control. In 1969, there were 7 infections for which there was an effective immunization. By 2012, there were 23 infections for which an immunization vaccine was routinely recommended for children. The complexity and cost of this immunization effort varies from year to year because the production of a certain vaccine will suddenly stop. The underlying issues are usually associated with low levels of industrial transparency. More frequently than not, these issues are seemingly related to profit.
Beginning in 1970, the complexity, cost and unpredictable character of the healthcare industry increasingly became the overall rule for our nation. In late August of 2013, the tetanus immunization most available also contained a vaccine for diphtheria as well as for pertussis, “whooping-cough,” was suddenly in limited supply. There was no advanced notice. By February of 2014, there was again no Public Health advisory, but it had become available in rationed supply.
TUBERCULOSIS AND ACCESSIBILITY
Co-incident with the first year of the POST-ANTIBIOTIC ERA, I finished medical school and began my residency training for internal medicine at an inner-city Hospital in New York City. Throughout my residency training that year, I became increasingly aware of the inequities characterizing our nation’s healthcare industry. It was also a year to learn that health care was about disEASE rather than DISease, and more often not, primarily a humanitarian problem rather than a scientific problem.
During my year of residency in New York City from 1969-1970, I served the needs of many patients who were suffering from tuberculosis (TB) and its complications. The ravages of TB within the inner city of New York City continue to be a vivid memory for me. With distant TB memories of persons suffering from scrofula, TB pericarditis and TB meningitis, I recalled reading with a special interest an Editorial in a September 2010 edition of the New England Journal of Medicine. The title of the Editorial was: “Tuberculosis Diagnosis – Time for a Game Changer.” Focusing on tuberculosis, Dr. Peter Small and Dr. Madhukar Pai (Small & Pai 2010) discussed the barriers that existed in 2010 for achieving a future reduction in the frequency of this illness.
The Editorial was a commentary on a new test using TB based on interferon. The new test represented a substantial improvement in the level of precision for establishing a diagnosis of TB. By expanding the use of this new test, the authors conclude width an opinion that “…the elimination of tuberculosis by 2050 might become a reality.” — 7 —
By any standard, this was a very optimistic opinion because TB is a contagious illness that is internationally spread from one generation to the next. One comment in the Editorial is probably more important than the 2050 prediction. Mid-way through the Editorial, the authors wrote:
“Health systems must be strengthened
so that patients do not delay in seeking care and
have prompt access to appropriate treatment
once they receive a diagnosis.”
I have added the italics to identify the fundamental problem of our nation’s healthcare. With an emphasis on responsive availability and accessibility, this statement represents the essential challenge for the reform of our nation’s healthcare. Any strategy for healthcare reform must first promote Primary Healthcare that is equitably available, ecologically & culturally accessible, justly efficient, and dependably effective for every resident person. Well before 2025, successful reform will require this level of health care for each and every resident person, especially for their Primary Healthcare.
EFFICIENCY PROBLEMS APPEAR
The essential characteristic of the POST-ANTIBIOTIC ERA was its rapidly escalating cost within our nation’s economy. In 1960, our nation’s healthcare spending represented 5.0% of our nation’s gross domestic product (GDP). In 2019, our nation’s health spending represented 18.0% of the GDP. This increase for 59 years occurred at the rate of 2.3%% compounded annually that had occurred in addition to economic growth. The spending increase, without any substantial improvement in our nation’s Population Health, probably represents a disappointing example of Parkinson’s Law. The Blog has a Sub-Page with that title for more information.
POPULATION HEALTH AND PRIMARY HEALTHCARE
This Blog reflects the carefully defined ideas of Eric Hofer, Leon Festinger, Carl Rogers, Thomas Kuhn, Lawrence Weed, Garrett Hardin, Peter Drucker, Stephen Covey, Michael Tomasello, and most importantly, Elinor Ostrom. As a basis for healthcare reform, the cohesion of their ideas, as well as the aspirations of many concerned individuals, represent the essential momentum to justify the need for a new institution, NATIONAL HEALTH.
Eventually, NATIONAL HEALTH would establish the traditions for promoting a continuously reforming healthcare industry that occurs in association with a locally initiated and nationally occurring reduction of social adversities. This reform process should assure that enhanced Primary Healthcare will become available and accessible as well as effective and efficient for every resident person. I propose that this Blog describes a means to this end, by a continuously sponsored and nationally sanctioned process to improve our nation’s Population Health, community by community.
Remember now, the admonition cited above from Marion Wright Edelman: we can no longer put off forming a nationally cohesive, collaborative endeavor to assure Stable HEALTH for every resident person, community by community.