The news is filled with divergent opinions on how health care should be financed in the United States. This debate, however, is really a thin veneer of a more fundamental and larger question. Where does the primary responsibility for the medical care of American citizens lie? The answer is likely within one or more of the four chief stakeholders of our health-care system: patients, physicians, hospitals and government.
Insight into this conundrum may be found in how medicine was practiced in older societies. While the diagnostic and therapeutic aspects of care have dramatically changed over the ages, exploring the history of the four main components of medicine in past civilizations reveals both similarities and differences to modern times. Potential answers for today's medical challenges become more evident when one understands the evolution of these segments.
The two most constant factors throughout the history of medicine are patients and doctors. The central role of the patient in the healing process was more ostensible in the past. With the transformation of medicine from a primitive science to one that required advanced education to understand, the average ill individual was relegated to a more passive role in their personal medical decisions.
In earlier times, the doctor's inability to isolate and treat a particular disease empowered the patient to be more actively involved in their personal health care. As a result, the ministration of illnesses and injures almost always began within the home. Here mothers were the principal health care providers whether along the shore of the Nile in early Egypt or near the banks of the James in Colonial America. The adult patient participated in the decision process with the family caregiver. For centuries individual accountability for one's health was the rule. But as advancement in medicine blossomed, the patients' personal responsibility diminished because of the multiple complex options that became available.
Early medical professionals did not have much to offer the sick other than what was available at the patient's home. Medicine for centuries was based on flawed theories. As a result, practitioners sought refuge in religion and severe treatment measures that usually hastened the demise of the gravely ill. Those that recovered were the lucky ones in which the doctor let nature take its frequent curative course.
Despite their ineffectiveness, many physicians were typically held in high esteem. Academically trained practitioners were prominent members of society in the Renaissance and pre-revolutionary America. As medicine became a science, the doctor's influence increased. Their independent authority was hard to challenge by the laity. With new breakthroughs the doctor's role expanded. The physician became the gatekeeper and patients' advocate to access the latest technology. With this the profession obtained significant political impact on how medicine should be practiced at all levels within modern society.
Rise of hospitals
Unlike the perpetual role patients and doctors have held in medical history the hospitals' place was initially more intermittent in importance. In Rome, specialized military structures were used as a place to treat injuries. In the Middle Ages, religious affiliated institutions treated minor problems, but were primarily a place that offered food and shelter to travelers. During the Renaissance, hospitals expanded to provide longer-term charitable care similar to almshouses in Colonial America
By the time of the American Revolution, hospital care began to change from being primarily custodial to treating acute disorders. Early in the 20th century improvement in surgical outcomes fostered significant hospital expansion. Today, the hospital is an essential element in modern medicine. This led to the formation of large hospital corporations. These companies are squarely in the middle of today's health-care system with significant political clout to engineer change.
In medical history's timeline, governments have participated at different levels of intensity in three ways: licensure of doctors, comprehensive public medical care, and as third party fiscal payers. Physicians have been regulated from as early as ancient Babylonia in Hammurabi's Code where ethical conduct and fees were prescribed. In early America, New Jersey had the first licensure law for the profession. But until the 20th century most governments took a laissez faire attitude toward physician qualifications.
Government sponsored healthcare occurred either directly through ownership of facilities and salary of physicians or indirectly by being a fiscal agent paying for medical service. In Egypt, the Pharaohs provided medical care for those building the pyramids. In ancient Greece, authorities paid physicians to care for the poor. In Italy during the Renaissance, government ownership of hospitals began. This approach spread to other countries and expanded to all areas of medical care over time. This is the prime reason European health care today is nearly all government sponsored.
In America the earliest direct government's involvement in medical care was under President John Adams who established the "Marine Hospital Service." This was the first pre-paid medical plan in the United States. Starting in the early 20th century multiple attempts were made to establish a European comprehensive health care model in the United States. They all met with failure. Instead in the 1940's the majority of Americans began to receive their medical care privately through employer-paid insurance. This changed with Medicare in 1965 and the Affordable Care Act in 2010. Both programs are taxpayer-financed care. With the regulations promulgated to support these measures, the government became a major driver of America's health care.
So has history provided any guidance for the solution to the question of which one of the constituents in our health care system is primarily responsible for medical care of American citizens today? The answer is yes.
It is apparent that the degree of influence of medicine's four components have evolved and changed over the centuries. The balance of power has shifted from the individual patient to hospitals and the government. The physicians' contribution has been diluted but remains seminal. A successful resolution to today's medical challenges both at the bedside and in the political arena requires a realignment of priorities that once again makes the patient the most important stakeholder.
Stolz is a retired physician with a longtime interest in the history of medicine. He is a regular instructor at the College of William and Mary's Christopher Wren Association where his 2017 Fall Term course is "Medicine in the Middle Ages and Renaissance.