Health Care of the Past

In the earliest civilizations health needs were met by a specific person or group. Ancient treatments were harmful in some cases and helpful in others. Some of the most helpful were the use of herbs and plants for medication. The World Health Organization (WHO) estimates that 80% of the world’s population use plants or herbal treatments as part of their primary care. According to the American Association for the Advancement of Science (AAAS), about 118 of the 150 prescription drugs sold in the United States originate from plants, fungus, bacteria, and extractions from animals. Some of these remedies, such as quinine for malaria and digitalis for heart conditions, are still in use today (Box 1-1; also see Medical Milestones on pp. 21-22).

Hippocrates (460-377 b.c.) is considered the father of modern medicine. He initiated the oath of practice that, in adapted form, most physicians still adopt (Box 1-2).

In early times plagues or epidemics caused millions of deaths. Many of these diseases are now preventable through vaccination and improved methods of cleanliness and sanitation (Fig. 1-1). Although communicable diseases still cause many deaths in less-developed countries, new technological advances are being used to provide better health care throughout the world.

In the past, the “patient” of the health care industry was a passive recipient of the treatment recommended by the health care professional. The relationship was a dependent one, with the health care provider as the guiding force. The patient often accepted without question the treatment suggested by health care providers.

Society has traditionally accorded respect to health care providers. The ancient Egyptians, Greeks, and Chinese who practiced the art of surgery or were witch doctors or neighborly herbalists all enjoyed stature in their communities. The arts of the past have become the professions of today (Box 1-3). These health care professions have many educational and training requirements.

Health Care of the Present

In the United States the focus of health care has shifted from the prevention of contagious diseases to those such as cancer, drug abuse, and heart disease, that are the result of lifestyles. Additionally, concerns relating to emergency response and preparedness services have become of primary concern to the health care industry (Table 1-1). Some communicable diseases are still a focus, including acquired immunodeficiency syndrome (AIDS), tuberculosis (TB), and flu. The WHO reported 33 million people living with AIDS worldwide in 2007. At the end of 2006, the Centers for Disease Control and Prevention (CDC) estimated that 1.1 million people were living with human immunodeficiency virus (HIV) or AIDS in the United States. It also reported a total of 12,898 cases of TB in 2008, which shows a decline of 2.9% from 2007 and 54% from 1980. According to WHO, nine Asian countries reported outbreaks of the H5N1 avian flu in birds by February 2006, six of which reported cases affecting humans. More than half of the confirmed cases were fatal. An outbreak of H1N1 swine flu was detected in April 2009. By July 2009 the CDC reported 43,771 cases; 302 of these patients died. The government has allocated money and the CDC has established preparation guidelines for a possible flu pandemic. Table 1-2 provides an overview of the pandemics and pandemic scares.

Institutional health care is provided by general hospitals, convalescent care centers, health maintenance organizations, home health agencies, and public health agencies (Table 1-3). Voluntary organizations provide education and support to individuals with specific concerns. The organizational structure of the facility defines the role of the health care worker (Fig. 1-2).

The federal agency that oversees the nation’s health care is the Public Health Services, which is part of the Department of Health and Human Services. It was established in 1798 to provide care for the American merchant seamen but has expanded to cover many other facets of health care (Box 1-4). The Department of Labor also regulates some health concerns through the Occupational Safety and Health Administration.

Health care is one of the largest industries in the United States. Currently the supply of workers is less than the demand, creating opportunities and job security in many areas of health care. The cost of health care in the United States continues to increase much faster than do other factors in the cost of living. The Kaiser Family Foundation reported the expansion of health care to 16.2% of the gross domestic product (GDP) in 2007. Some of the reasons for rising health care costs are the advanced technological developments, malpractice litigation, increase in longevity, and disaster relief expenses.

In 2007 the Commonwealth Fund’s annual survey found that the U.S. health care system to be the most costly and consistently underperforming, compared to the seven countries considered. According to the U.S. Treasury Department, a 2008 census report indicated that 15.4%, or 46.3 million of Americans, did not have health insurance.

In March 2010 the U.S. government passed the Affordable Care Act. Some provisions in the legislation took effect in 2010, with others becoming effective in 2014. For example, children with preexisting conditions will not be denied insurance on that basis beginning in 2010. Small business owners will receive a tax credit of up to 35% of their premiums to insure employees. The constitutionality of some provisions of the bill, such as the mandatory requirement for individuals to have health insurance, is being challenged.

Medicare is the federal health program for individuals 65 or older, certain younger people with disabilities, and people with end-stage renal disease. Since 1984 Medicare has reimbursed for services on the basis of the diagnosis instead of the actual cost. Diagnosis-related groupings (DRGs) have greatly affected the health care industry by shortening the time allowed for treatment. In 2005 Medicare began offering a prescription drug plan for applicants. Medicaid is a joint program between the federal and state governments. It helps provide health care coverage for individuals with low income and limited resources. Programs for Medicaid vary from state to state. The Social Security Act established both Medicare and Medicaid in 1965.

Insurance companies have established options designed to lower or tailor the cost of coverage to the individual need. These include managed care models, increased deductibles, coinsurance, copayments, and preventive care. Managed care insurance plans include health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service (POS). In one type of HMO described as the staff model, the health care providers are employed by the organization and work in a designated facility. The independent-practice association model contracts physicians and other health care providers to provide care to the HMO members. POS plans generally allow members to select treatment either “in network” or, for a greater cost, “out-of-network.”

The traditional model of insurance (fee-for-service) may also include cost-containment measures similar to those of managed care. The insured person may choose a plan that provides a percentage of the cost or a specified amount (Table 1-4).

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