Guide to U.S. Health and Health Care Policy

Thomas R. Oliver

• Publisher: CQ Press
• Year: 2014
• Print ISBN: 9781452270739
• eBook ISBN: 9781483370453
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Political History & Theory
• Index: Politics & International Relations

The contentious passage of the Affordable Care Act in 2010 highlighted the incredible complexity and controversy surrounding health care in the United States. While the U.S. federal government does not provide universal health care, it has an extremely wide reach when it comes to the health of its citizenry. From important scientific and medical research funding to infectious disease control and health services for veterans and the elderly, the pathway to legislation and execution of health policies is filled with competing interests and highly varied solutions.

The Guide to U.S. Health and Health Care Policy provides the analytical connections showing researchers how issues and actions are translated into public policies and institutions for resolving or managing healthcare issues and crises. The Guide highlights the decision-making cycle that requires the cooperation of federal and state governments, business, and an informed citizenry in order to achieve a comprehensive approach to advancing the nation's healthcare policies.

Through 30 topical chapters, the book addresses the development of the U.S. healthcare system and policies, the federal agencies and public and private organizations that frame and administer those policies, and the challenges of balancing the nation's healthcare needs with the rising costs of medical research, cost-effective treatment, and adequate health insurance.  Additionally, the book comprehensively addresses significant disparities that exist in the U.S. system and the challenges to public health posed by our increasingly connected world.

Taking a comprehensive approach, the Guide traces policy initiatives across time and takes into account the most recent scholarship:

 

Part One: Evolution of American Health Care Policy

Looks at the emerging and expanding role of government in the health care sector and the position the U.S. occupies today as the only advanced industrial nation without universal health care.

 

Part Two: Government Organizations that Develop, Fund, and Administer Health Policy (1789-Today)

Examines the role each branch of government plays in the forming, executing, and regulating health care policies.  The authors examine the origins, organization, budget, and function of major government organizations including the FDA, CDC, and VA. An exploration of legal oversight and the roles states play in the health sector round out this section.

 

Part Three: Contemporary Health Policy Issues: Goals and Initiatives (1920s-Today)

Explores the wide range of players in the health care sphere and the role the government plays, particularly in funding them. Special attention is paid to policy issues surrounding medical research and medical professions. This section also looks at the ethical issues in play when making health policy and the inequalities that have plagued the U.S. health care system.

 

Part Four: Contemporary Health Policy Issues: People and Policies (1960s-Today)

This part of the book looks in-depth at health disparities in the U.S., health challenges particular to specific groups, mental health, obesity, and the influence of interest groups.

 

Part Five: U.S. Response to Global Health Challenges (1980s-Today)

The last section of the book looks beyond the borders of the United States and the serious challenges posed by our increasingly connected world.

 

 

PART I

EVOLUTION OF AMERICAN HEALTH CARE POLICY (BEGINNINGS TO TODAY)

CHAPTER 1	Origins and Development of Government’s Role in Health Policy (Colonial Era to Present)
CHAPTER 2	The Long Struggle for Universal Health Care (1900s–Present)

chapter 1

Origins and Development of Government’s Role in Health Policy (Colonial Era to Present)¹

Kant Patel

THE UNITED STATES REMAINS THE ONLY MAJOR industrialized country in the world without national health insurance. Today, a majority of Americans are covered through private health insurance, usually bought through their employers. Health care is largely financed, administered, and delivered through the private sector. However, it is important to note that if one uses internationally accepted standards for health accounting, public spending accounts for almost 60 percent of U.S. spending on health care. This discrepancy arises because, in the United States, tax expenditures of state and local government on health coverage for their employees and retirees are counted as private spending.

The federal government today performs a variety of important roles in the health care field. First, the federal government in collaboration with state and local governments performs public health functions through the Centers for Diseases Control, Department of Agriculture, and Department of Defense. Second, the federal government provides health services to veterans, American Indians, and Alaska Natives. Third, through public health insurance programs such as Medicare, Medicaid, and the Children’s Health Insurance Program, the federal government covers the health care needs of individuals—such as the elderly, the poor, the permanently disabled, and poor children who cannot afford private health insurance for one reason or another. Yet almost forty-eight million Americans fall through the holes in this safety net and remain uninsured today. Although the United States spends far more on health care than any other country in the world, it does not rank near the top on many health care indicators and suffers from problems related to high costs, access, and inequality.

Perhaps it is not too surprising that scholarly and journalistic literature has described the U.S. health care system as broken, sick, a disgrace, wasteful and built for waste, scandalous, accidental, an oxymoron, fragmented, and unsystematic.² The patients in the U.S. health care system are often described as overdosed, overtreated, and overdiagnosed.³ The present-day health care system has evolved over several centuries into a patchwork of public and private sector health programs and policies, often without any coordination.

HEALTH CARE IN COLONIAL TIMES, 1600s–1700s

In an effort to alleviate potential settlers’ and investors’ widespread anxieties about the dangers of migrating to North America and the potential hostility of Native Americans, early explorers at the beginning of the 1600s described the eastern sea coast (present-day New England) in idyllic terms as made up of bountiful gardens and a paradise that would be hospitable and healthy for their constitution as well as support European plantations with minimum efforts.⁴ Instead, what the new settlers found was a world that was a melting pot of disease such as malaria, typhoid, and yellow fever.⁵ Settlers also brought several diseases with them to the Americas. Colonies were often swept by deadly epidemics, such as smallpox, measles, scarlet fever, plagues, typhus, and diphtheria, against which doctors were helpless.

Out of necessity, the doctors relied on Old World medicine and practices such as purging, puking, sweating, and bleeding since modern medical procedures and pharmaceuticals were not yet developed. The drugs they used were primarily medicinal herbs, called “simples,” which seldom relieved the patients’ symptoms; beyond that, doctors could do little else but offer moral support.⁶ In the early settlements, European trained doctors were very few, and they existed in short supply as the population grew. Consequently, colonists were forced to train their own doctors by a system of apprenticeship or send young men of promise to Europe for proper medical training.⁷

European medicine has a rich history and it began with the age of Pericles. It was Hippocrates (460–370 bce) who is credited with giving Greek medicine its scientific foundation and its ethical ideals. He has been called the “Father of Medicine” and is known for, among other things, disassociating medicine from philosophy, organizing existing knowledge into systematic science, and giving physicians high moral aspirations.⁸ The Greek medicine ultimately migrated to Rome and established a respectable footing. Romans made hygienic contributions to science, such as cremation, well-ventilated houses, sewers, drains, and public baths. The fall of the Roman Empire ushered in the Middle Ages (1096–1438) and the period of feudalism. The Christian virtue of compassion for the weak and suffering led to new directions in nursing the sick and building hospitals for their care. It also led to advancement in medical laws and chartering of medical universities. The period of the Renaissance (1400s–1600s) led to revival of learning and reformation. During this period the invention of printing, revival of learning, discovery of America, and advancement in travel and commerce laid the foundation of modern physics and chemistry. The seventeenth century was characterized by individual scientific endeavors. English medicine produced the first book on vital statistics. The condition of medicine was further improved by creation of scientific societies. By the seventeenth century, Europe had become the great center of medical education.⁹ Thus, it is not surprising that colonists sent their young men of promise to Europe for medical training.

Epidemics and Little Treatment

A series of epidemics struck the eastern seaboard of New England between 1616 and 1619 and wiped out nearly 95 percent of the Native Americans living there. The Native Americans were described by early travelers and settlers as the enemies of God’s chosen people, and the effect of the plague was described as having made the region much more fit for the English people to inhabit. Thus, the settlement of New England was seen as divinely ordained by the colonial ideology and as further evidence that Christ had endorsed the migration. The plagues were viewed as a divine force acting directly on the “Promised Land,” opening the space for migration and cultivation.¹⁰

Of course, the English settlers were by no means immune to the same diseases. Many of them were also stricken by epidemics of smallpox, measles, and diphtheria. Because the colonists during that time had very little understanding of the transmission or nature of most diseases, sickness was generally attributed to an act of God. The smallpox epidemic in 1689 was considered an act of God.¹¹ Faith in divine protection against illness helped raise morale, but it also created a fear of divine wrath.¹² The 1721 smallpox epidemic that struck New England was believed to be God’s punishment to colonists for breaking their covenant with him.¹³ This link between medicine and theology in New England lasted throughout the seventeenth century and was fused into the religious life of the Puritan community.¹⁴ It is not too surprising, then, that health guides and medical advice during that time consisted of urging individuals to avoid behaviors and emotions (anger, fear, grief, envy) that could lead to ill health and diseases. Health was seen as a private good and individual responsibility.¹⁵

Many of these diseases came from Europe, and vaccination to prevent disease such as smallpox was not available until 1800. Consequently, attempts were made to block importation of such diseases by the establishment of quarantine at the seaports as early as 1648. The quarantine function during the colonial times was left up to local governments. Because these quarantines were imposed by the government, one can argue that the principle of government responsibility for the safeguarding of the public’s health was established.¹⁶ In recognition that overcrowding on a ship can pose serious health problems, one of the first public health laws in Massachusetts limited the number of passengers on a ship based on the size of the ship. In addition, a vague sense of connection between sickness and purification led the town of Boston in 1634 to prohibit residents from depositing fish or garbage near common landings.¹⁷ The end of the Civil War (1861–1865) helped usher in the sanitary revolution in the United States, and by the end of 1860s, most cities had established effective health boards.

Relief for the Poor

Provision for the sick poor in colonial America was essentially seen as a problem of relief for the poor; programs for relief varied considerably among colonies. The English settlements again adopted the principle of local responsibility as set down in the Elizabethan poor law of 1601 under which each parish or town was responsible for taking care of its own needy individuals. Responsibility for relief of the poor in the sparsely populated southern colonies was vested in the county rather than in a parish or a town. In 1642, in accordance with English customs, the Plymouth Colony passed a law making each town responsible for its own poor. However, it was not uncommon to see pregnant women, the sick, disabled, or homeless driven out of town to avoid the burden of taking care of them. Even in towns that provided help and care, the sick poor were granted minimal material and medical relief. Institutional provision for the sick was rare; instead, clergy generally undertook visitation of the sick. The main feature of the colonial provision for the care of the sick poor was its very unsystematic nature.¹⁸

By the early 1700s, most colonial assemblies had established the practice of quarantine at their ports to prevent spread of diseases. The first preventive medicine, a smallpox inoculation, was imported from Great Britain in 1720, which was followed by improved vaccination around 1800.

Key Developments in Health Care Policy

Several important developments occurred in the second half of the eighteenth century. Many of these developments were influenced and shaped by policies developed in Europe and were subsequently adopted in colonial America. Developments in American medicine regarding medical schools, medical training, hospitals, and medical treatment were significantly influenced and shaped by medical developments in Europe. For example, doctors in colonial America took eighteenth century England as their model in establishing the social structure of medicine in early America in an attempt to transform physicians from an “occupational profession” to a “status profession.”¹⁹

One was the development of public health policies and sanitation laws passed by local governments: regulating butchers, requiring cleanliness in slaughterhouses, impounding stray cows and horses, and requiring the removal of dead animals from the streets. The increasing population and crowded conditions in growing cities also led local governments to pass laws regulating food and water supplies.

The second major development was the creation of university medical education with the establishment of the first medical school at the College of Philadelphia in 1765, followed by the medical school of King’s College in New York in 1768. However, this development was disrupted by the American War of Independence (1775–1783).²⁰

The third major development was the emergence of hospitals. Hospitals in the eighteenth century, however, were rare and generally found in urban areas such as New York and Philadelphia. One category of hospital that emerged frequently in the second half of the seventeenth century was the military hospital; they varied in the comprehensiveness of the services they provided, which ranged from mobile “lying hospitals” to permanent regimental hospitals to general hospitals.²¹

The origin of the federal government’s role in health policy following independence can be traced to provision of medical and hospital care for merchant seamen and sailors when, in 1798, Congress passed an Act for the Relief of Sick and Disabled Seamen to finance the construction and operation of public hospitals at seaports. This was the first instance in which any level of government established a health program for a specific group of people (e.g., the Marine Hospital Service, renamed the Public Health Service in 1912).²²

Thus, throughout the eighteenth cent...

Table of contents

• Cover Page
• Halftitle
• Title
• Copyright
• Summary Table of Contents
• Table of Contents
• List of Illustrations
• About the Editors
• Contributors
• Introduction: Beyond the Stable State–New Challenges and Directions for U.S. Health Policy
• PART I: Evolution of American Health Care Policy (Beginnings to Today)
• PART II: Government Organizations that Develop, Fund, and Administer Health Policy (1789–Today)
• PART III: Contemporary Health Policy Issues: Goals and Initiatives (1920s–Today)
• PART IV: Contemporary Health Policy Issues: People and Policies (1960s–Today)
• PART V: U.S. Response to Global Health Challenges (1980s–Today)
• Appendix A: Selected Federal Health and Health Care Agencies and Offices
• Appendix B: Bibliography
• Index