Scientific advances taking place in the early twentieth century were destined to have a significant impact on diagnostic and therapeutic interventions available to physicians, the understanding of disease patterns, and the nature of medical education and physician preparation for the emerging modes of practice. Discoveries in the natural sciences and the increasing availability and applications of the compound microscope fostered the development of pathology, bacteriology, physiology, pharmacology, and biochemistry as sciences basic to the study of medicine. The development of x-ray examinations, electrocardiography, and laboratory examinations of body fluids, based on new knowledge in physics and chemistry, were beginning to...

Although physicians were considered authorities on all matters medical, in the mid-twentieth century measures designed to deal with the fact that medical care had become more effective and, not coincidentally, more expensive, did not generally emanate from the medical community. Medical educators were busy educating, medical researchers were busy doing research, medical specialists were consolidating their newly founded societies, and general medical practitioners were represented by the American Medical Association (AMA), which was busy trying to fend off legislative initiatives. As a consequence of the virtual lack of interest in undertaking actions designed to influence events taking place outside the...

Many Americans may find it difficult to appreciate the impact of the social ferment of the mid-1960s associated with the civil rights revolution and President Lyndon Johnson’s declaration of a “War on Poverty.” The 2000 census reports that today’s median age is 35.3 years. Thus over half our population had not yet been born four decades ago when the Civil Rights Act of 1964 was enacted and when the President articulated his goal of creating a “Great Society.” They may not understand the significance of the Voting Rights Act of 1965, of place names like Montgomery or Selma, of terms...

Health care and the nation’s health status are dependent on many factors. Important as health insurance and access to health care services are, they are only two of many variables affecting the health of the population, and thus only two of the many variables with which all administrations should be concerned. It is easy to focus on the various economic arrangements in health care because they are important, the subject of government activity, and the center of media attention. That focus, however, makes it easy to overlook the purpose of the various economic arrangements and of the economic activity in...

It is understandable that when, as at the end of World War II, health expenditures were approximately 4.5 percent of GDP, investors and financiers had little interest in the health sector. But by the mid-1980s, as national health expenditures increased to over $400 billion and almost 11 percent of the GDP, financiers saw the delivery of health care services as a significant part of the American economy and an area for potential investment and possible profit. The interest in health delivery organizations that generated profits was not an entirely new development: for-profit hospitals had long existed, mainly in the southern...

The public certainly has many valid reasons to value health care services. Nonetheless, as in earlier time periods, major improvements in vital statistics are due to factors that can be considered outside the medical care delivery system. Improvements in living conditions, nutrition (albeit, the latter increasingly offset by obesity), and environment, as well as changes in behavior (for example, the decline in smoking and increase in exercise) have made the actual difference. Efforts to quantify the impact of medical care have suggested that perhaps it accounts for 10 percent of the improvements to public health.¹ Given the very large economic...

In these, our concluding chapters, we look to the future. None of us know precisely how the United States will change during the twenty-first century, the “values” that will impel us in the years ahead, the shape of our international relations, the size and nature of our economy, the structure of our society, the particular ways in which medicine will evolve, and what “revolutions” will occur. Nevertheless, we do know that today’s health care system, the manner in which it is organized, its level of funding, and the ways that health services are financed for and by our population are...

The most recent major effort to enact a comprehensive universal insurance program was the Clinton plan of 1993. As discussed earlier, while many factors contributed to its failure of adoption, especially significant was the growth and concomitant power of the insurance industry and of its lobbying capacities. The industry exploited the general ambivalence about government’s ability to manage large-scale programs (perhaps captured most cynically in the bumper sticker, “If You Like the Post Office You’ll Love National Health Insurance”). Earlier positive attitudes toward government’s capacities, as reflected in public approval of the Manhattan Project and the mission to land a...