This is a 150-200 word answer. I have attached the Chapter You only need to pick one time period to discuss.This chapter provides a timeline in comparison to healthcare changes over time. Pick a time period and discuss the health changes/implications at that time.
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Hennepin County Medical Center Whittier Clinic, Minneapolis, Minnesota; Hammel, Green and
Abrahamson, Inc. Photography by Paul Crosby
Chapter 7
Politics and Healthcare
Overview
Political decisions and other factors will shape the design of clinics in the future. Looking
backward long enough to learn from the past, architects, interior designers, and other building
industry professionals can develop a deep understanding of the history of care and how the need
for environmental awareness can shape the future. Medical buildings today must meet immediate
and long-term future needs.
This is an especially opportune moment for reviewing the historic interplay between politics and
healthcare because healthcare reform is still in the early phases of implementation in the United
States, and it is substantially altering the way that medical services are being delivered.
As has been the case in the past, politics and healthcare are clearly influencing each other, with
the relationship ranging from synergistic to symbiotic or adversarial, depending on the specific
issue at hand.
1600s–1700s
The first form of government healthcare starts in 1636 when the Pilgrims of the Plymouth colony
vote to provide care for disabled soldiers, supported by the colony. During the Revolutionary
War, the Continental Congress provides pensions to disabled veterans. By 1811 the first
domiciliary is authorized by the federal government, providing care for wounded soldiers and
veterans.
1800s
Abraham Lincoln in his second inaugural pronounces: “To care for him who shall have borne the
battle and for his widow and his orphan,” President Lincoln makes a commitment that all the
veterans will be cared for.1 During his term these benefits are extended to widows and their
dependents. After the Civil War, the states provide care through domiciliaries.
During this century the prevailing belief is that the sick should be treated at home and paupers
treated in hospitals. Public policy reinforces this belief. The post–Civil War era brought
advances in medicine and the treatment of diseases. During the late 1800s a more central and
organized medicine takes shape in urban areas of the United States.
Politics
Throughout the 1800s, the U.S. government takes no action to subsidize voluntary funds or make
insurance for the sick compulsory. Instead, it leaves these decisions to the states, and the states
leave these to private and voluntary programs.
The Roman Catholic Communities of Nuns is a key group that provides healthcare services for
those who lack the means to pay for it. These sisters believe it is their mission to care for the
poor and sick. By 1875, there are 75 Catholic hospitals in the United States. By the beginning of
the 20th century this number nears 400. Over time, the Roman Catholic Church becomes one of
the largest non-government providers of healthcare services in the world.2
Healthcare
By the latter part of the 19th century, advances made by medical professionals and
improvements in hospital facilities lead more members of the general populace to seek care at
inpatient facilities. The field of medicine is increasingly viewed as scientific and those who want
to practice it are required to obtain a standard level of education. Thus, from the late 1800s
onward, the education of healthcare professionals blends firsthand experience with scientific
research.
In the 1870s, for example, the State University of New York’s (SUNY) medical school becomes
the first in the nation to be founded within a hospital so bedside training can be integrated into
the medical students’ curriculum. In 1893, Johns Hopkins University’s Medical School
revolutionizes physicians’ formal training by stressing scientific methods and combining
laboratory research with professional practice.
San Francisco sees several healthcare facilities open in the 1800s. The California Pacific Medical
Center has its start through the efforts of leaders of the German immigrant community. The
German General Benevolent Society leads in constructing a hospital between 1856 and 1858. In
1871 the Episcopal Diocese of California opens St. Luke’s Hospital. In 1875 the Pacific
Dispensary for Women and Children is founded, in large part through the efforts of Charlotte
Amanda Blake Brown. It is a facility for women and children run by women.
Florence Nightingale (1820–1910)
The spread of infection is also a major focus in the work of nurse Florence Nightingale, who
believes that disease arises spontaneously in dirty and poorly ventilated places.3 Although these
beliefs prove to be only partially accurate, they make sense because hospital wards at the time
have more than 100 beds with multiple patients in each ward. They lack sufficient light, are
poorly ventilated, and are unsanitary. Infectious patients are not properly isolated.
Nightingale’s work leads to improvements in hygiene and healthier interior environments. She
also advises on the development of district nursing and the establishment of a training program
in Liverpool, England.
Nightingale and her nephew, Sir Douglas Galton of the Royal Engineers, test some of her
theories by developing the pavilion design that Galton then uses in the design of the Royal
Herbert Hospital. Each ward in this hospital connects to a central corridor to optimize access to
natural light and ventilation. Each ward also has a large window at its end to provide patients
with exterior views. St. Thomas Hospital in London and Johns Hopkins Hospital in Baltimore
also use this plan.
1900s
Two other women help frame healthcare in the San Francisco area. Alta Bates opens the Alta
Bates Sanatorium, now the Alta Bates Summit Medical Center, in 1905. She does so with credit
from local merchants and $100 cash. Plans for the facility come from her father. Elizabeth Mills
Reid, a prominent Millbrae community member, opens a six-bed facility in 1908.
By 1900 several rural areas begin to organize and construct hospitals.
The first decade of the 20th century is considered by many historians to mark the beginning of
organized medicine. This is a time when people, typically more affluent, donated time and
money to develop hospitals.
Theda Clark is the daughter of Charles Clark, who helps found Kimberly-Clark Corporation.
Charles Clark is also a town mayor and later a member of Congress for Wisconsin. Theda is also
a community activist who helps build the Neenah, Wisconsin, public library. She dies just after
childbirth, leaving a $96,000 bequest. Her family uses this money and an additional $30,000 to
build the Theda Clark Memorial Hospital that opens in Neenah in 1909.4
In 1917 a new system that includes insurance, disability compensation, and rehabilitation comes
into being. These services are administered by three different agencies. In 1930 Congress
authorizes the president to consolidate these services, and the Veterans Administration (VA) is
created. The VA currently has more than 152 hospitals, 800 clinics, 126 nursing homes, and 35
domiciliaries.5 In 1918, just after a devastating flu epidemic, Sacramento doctors and a civic
leader come together to build a new hospital to meet the needs of the city. The hospital, one of
California’s finest, opens in 1923. Another first comes in 1937, when Sutter Health opens a
satellite hospital, the first institution in California and the second west of the Mississippi River to
operate more than one facility.
During the first few decades of the 20th century, there is a shift in the design of hospitals from a
sanatorium design to a hospital design. Most sanatoriums are not built for medical care. Many of
them are converted from large homes, old schools, or public buildings into facilities where
patients with communicable diseases like tuberculosis are treated. In some cases, small
sanatoriums of four to eight beds are constructed and become the first hospitals in the
community. Over the next 40 years, the older buildings will be surrounded by newer wings to
form what we recognize as modern hospitals.
Politics
The 20th century opens with the rise of the Progressive Era, during which reformers strive to
improve social conditions for the working class. President Theodore Roosevelt supports “social
insurance” on a personal basis because he believes that a country cannot be strong if its citizens
are sick and poor. However, most of the reform that occurs is outside of the public realm. For
example, railroad companies develop extensive employee medical programs.6
Healthcare
The American Medical Association (AMA) becomes a national force after consolidating the
support of state and local associations into a single national organization. Between 1900 and
1910, its membership grows from 8,000 to 70,000 physicians—approximately half of the doctors
then practicing medicine in the United States.
Surgery becomes common for removing tumors, infected tonsils, and inflamed appendixes, as
well as for addressing issues of gynecological health. Public health nursing is now widespread
after Lillian Wald pioneers the idea of stationing nurses in public schools to help increase school
attendance.
Although the charitable missions of most hospitals survive, doctors are no longer expected to
provide free services for all hospital patients. Like other buildings, healthcare facilities are
transformed by the use of electric lights, elevators, central heating and ventilation, and new
processes for cleaning and deodorizing interior spaces.
Doctors identify the first case of a healthy disease carrier in Irish immigrant and cook Mary
Mallon, who is later labeled Typhoid Mary because she spreads this disease to dozens of other
people who live in the households where she has worked.
George Soper, an engineer for the New York City Department of Health, identifies Mallon as the
disease carrier and has her committed to an isolation center in the Bronx. She is released in 1910,
with the proviso that she will never accept employment that involves handling food. She breaks
this promise and is thought to cause typhoid outbreaks at a sanatorium in Newfoundland, New
Jersey; and at Sloane Maternity Hospital in New York City. She had worked as a cook at both of
these locations. She is returned to North Brother Island, where she spends the rest of her life.7
How a person can infect others without succumbing to a disease remains a mystery for decades.
In 2013, however, scientists determine that the Salmonella bacteria that causes typhoid fever can
hide in immune cells known as macrophages and “hack” into their metabolism to survive without
the infected person developing symptoms.8
1910s
Once Woodrow Wilson is elected president (1912) and the United States is drawn into the First
World War (1917), momentum for providing sickness insurance for those in need wavers and,
ultimately, dies. Germany has compulsory sickness insurance and, thus, “German socialist
insurance” is denounced as inconsistent with American values.9
Politics
In 1913, the American Association for Labor Legislation (AALL) holds its first national
conference to address the issue of “social insurance.” Its leaders draft a model bill in 1915 that
limits health insurance coverage to the working class and the poor. This coverage includes
paying for the services of care providers and other hospital-related expenses as well as sick pay,
maternity benefits, and a death benefit of up to $50 to cover funeral expenses. Costs for this
program are to be shared by workers, employers, and the states.
Initially, members of the AMA support this bill. In 1916, the AMA’s board appoints a committee
to work with the AALL to promote this legislation. However, when a number of state medical
societies express opposition and disagreements arise over how to pay physicians, the AMA’s
leadership withdraws its support.
At the same time, Samuel Gompers, the president of the American Federation of Labor (AFL),
criticizes compulsory health insurance “as an unnecessary paternalistic reform that would create
a system of state supervision over people’s health.” AFL leaders are concerned that a
government-based insurance system could weaken unions by taking over their role of providing
social benefits to workers.10
The commercial insurance industry adds its opposition to the discussion. In response to a general
fear among working-class people that they will “suffer a pauper’s burial,” insurance companies
have already been offering policies that pay death benefits and cover funeral expenses. The
AALL’s health insurance plan also covers funeral expenses, and this creates unwanted
competition for the association. The national debate over compulsory health insurance is
suspended and does not resume until the 1930s.11
Healthcare
U.S. hospitals are now considered modern scientific institutions where cleanliness is highly
valued. The need for private rooms begins to increase, although wards with many beds are still
commonplace. The prevalent cause of death remains contagious diseases. The 1918 flu outbreak
kills more than 600,000 people. It does not completely subside until the 1950s.
After Italian researchers discover and demonstrate how malaria parasites are transmitted to
humans by infected mosquitoes (1899), a medical team led by Dr. William Crawford Gorgas, the
chief sanitary officer for the Panama Canal project, applies this knowledge to develop a
mosquito control program in Panama. Standing water is drained or has insecticide and oil added
to it, adult mosquitoes are collected, and government buildings and workers’ quarters are
screened-in to keep mosquitoes out. As a prophylactic measure, quinine is given to workers.
This multipronged disease-control strategy substantially reduces malaria-related illnesses and
deaths among canal workers. In 1906, there are more than 26,000 workers assigned to this
project, and more than 21,000 of them are hospitalized for malaria at some point. By 1912,
approximately 5,600 of the 50,000 canal workers fall sick with this disease.
In 1914, Congress approves funds for the Public Health Service (USPHS) to control malaria in
the United States. The USPHS establishes malaria control activities around military bases in the
South, where this disease is a significant health threat.12
1920s
During this decade, there is limited government or citizen attention to the matter of health
insurance. The fact that the relative cost of medical care begins to rise, however, does shift the
emphasis of the public discourse to creating a social insurance program that would cover the cost
of medical care rather than the loss of wages to sickness. The medical profession gains prestige,
and a rise in physicians’ salaries accompanies this increase in influence. The decade ends with
the onset of the Great Depression.
Politics
The general attitude of complacency toward politics means that there is no strong, broad effort to
reform health insurance during this period. There is some progress toward improving access for
portions of the population with specific needs.
For example, in 1921, Congress passes the Sheppard-Towner Maternity and Infancy Protection
Act, marking the first federal program specifically created to serve women and children. At this
time, the vast majority of women (80 percent) receive no prenatal advice or professional care.
This, combined with poverty, leads to high rates of infant and maternal mortality. The act expires
after eight years but is not renewed. During the time the act is in force, infant and maternal death
rates fall by 16 percent and 12 percent, respectively.13
Healthcare
Although scientists and others had experimented with the phenomenon of “anti-biosis”14
(“against life”) in the 19th century and some folk traditions used fungi and mosses for wound
treatment earlier than that, no progress is made in developing a substance that can be used for
medical treatment until 1928, when Alexander Fleming accidentally discovers penicillin.
Although this is one of the most important discoveries for the fight against infectious diseases,
20 years pass until penicillin is commonly used. During World War II, penicillin will save many
lives on the battlefield and in the hospital. This success prompts scientists to search for other
microorganisms that can be used to combat infections.
In 1926, the Committee on the Cost of Medical Care (CCMC) meets to address concerns over
the cost and distribution of medical care. This private group includes 50 economists, physicians,
and public health specialists, as well as major interest groups. The CCMC’s research reveals that
a general need for more medical care exists. Its findings are published in 26 research volumes
and 15 reports over a period of five years. It recommends that more national resources be
allocated for medical care and that premiums from voluntary health insurance be used as the
primary means for covering these costs.
In 1929, a group of teachers arranges for Baylor Hospital in Dallas, Texas, to provide room,
board, and specific medical services for a predetermined monthly cost. This agreement becomes
the forerunner for Blue Cross health plans.
1930s
In the 1930s, the public’s focus shifts to expanding access because for most workers, the cost of
medical care is now higher than the wages lost due to illness.
Politics
The Great Depression begins, and this further limits people’s ability to afford medical care. After
being sworn into office in early 1933, President Franklin Roosevelt begins to draft social security
legislation. Initially, this includes publicly funded healthcare programs, but he later removes
these in response to organized opposition from groups such as the AMA. The Committee on
Economic Security also fears that including public health insurance in the bill will weaken its
chances of passing.
In 1935, President Roosevelt signs the Social Security Act into law. It includes programs for oldage assistance and retirement benefits, unemployment compensation, aid for dependent children
and the disabled, and maternal and child welfare. The monthly benefit ranges from $10 to $85,
remaining in this range until the 1950s.
Although some view the Social Security programs as necessary humanitarian measures, others
worry that the programs will discourage people from working, because they can collect
unemployment insurance, or from saving, because of the old-age and survivors benefits. The act
also disregards sickness, which is the main cause of joblessness at this time.
A second push for national health insurance (NHI) comes from the Tactical Committee on
Medical Care. This time, progress is stonewalled by southern Democrats, who align with
Republicans to oppose the government expansion that passing any additional New Deal social
reforms would require. The Wagner Bill, or National Health Act of 1939, which supports a
national health program funded by federal grants to states, is introduced in the Senate. It dies in
committee.
During World War II, government-mandated wage freezes prevent employers from using
monetary compensation to woo workers during a labor shortage. The Internal Revenue Service
addresses this with Section 104 of the Revenue Act of 1939, which allows companies to count
benefits of up to 5 percent of the value of an employee’s wages as nontaxable compensation.
These include workers’ compensation, as well as accident and health insurance. This ruling later
becomes permanent (1954) and helps lay the foundation for the present-day insurance system in
the United States.15
Healthcare
Individual hospitals begin to offer their own insurance programs. The first of these is Blue Cross,
which offers private health insurance in locations across the United States. Groups of hospitals
and physicians’ groups, such as Blue Shield, also begin to sell health insurance policies to
employers, who offer these to their staff and collect the premiums.
During the 1930s and continu …
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