Thursday, November 29, 2012

How Obamacare Compares To 19th Century Care

What was health care like in the “good old days”? And what was the government’s role? Today to relieve the taxpayer from the obligation to pay the hospital costs for the uninsured, the country is preparing for “Obamacare,” a mandate for everyone to have health insurance.

Before the 20th century, people did not bother with health insurance nor did they voluntarily go into a hospital, a source of infection and death. Only sailors had a mandate to pay into a federal program for medical care. The poorest, the homeless, those lacking social support like the sailors, were condemned to hospitals where doctors volunteered their services in return for the prestige of the appointment. Hand-washing was not expected and the results were deadly.

Neither professional nor government regulation existed to establish standards of care or of competency. There were no licensing requirements for those practicing medicine. Anyone could call himself a doctor and anyone, male or female, could practice medicine. That included the traditional Indian shamans, African-American conjurers or obeahs, midwives, or any herbal dispenser. By the nineteenth century there were even more unorthodox treatments and self-help alternatives from hydropathy to homeopathy to a profusion of sugarcoated patent medicines with unknown ingredients (the patent was on the shape of the container and not what was in it).

Those who consulted doctors on a fee basis paid cash or farm produce to be bled, purged, or treated with some foul-smelling obnoxious potions or pills. They had no guarantee of a cure but they were guaranteed an unpleasant reaction to those “heroic” medications, which supposedly rid the body of the disease. The prescriptions were often useless and could be harmful if not deadly. If the patient died, no one blamed the doctor’s cure; it was blamed on the patient’s neglect. Nor was there any promise that the American doctor knew anything about anatomy or diseases. In days before the Civil War little was known about the cause of disease or how to distinguish between diseases. Symptoms told it all—a fever, a skin eruption, a fast pulse, a swelling, bleeding, an “ague.” Doctors as well as folk healers diagnosed based on the patient’s description of the ailments and then treated the symptoms.

There was no price control from insurers or the government to worry about, nor was there a way to test the ability or training of doctors. A bootblack from England turned himself into a dispenser of special medications, used the newspapers to advertise and the postal system to mail his nostrums, and then created an even more fictitious medical history to call himself a doctor. It was a lucrative business. Early American medicine was free enterprise at its most pure, a libertarian’s dream.

Such was the nature of health care before the twentieth century. Anyone could practice with no interference from government or professional organizations.  America in the nineteenth century was an entrepreneurial paradise that valued commercialization over the public interest. The medical man could make his fortune like the factory owner or any other business innovator and the most imaginative and unscrupulous did prosper.  In the area of health care Americans retained what one medical historian called their “inalienable rights to life, liberty, and quackery.”

But all was not lost. Europeans in the nineteenth century were forging ahead with careful training, creating laboratory-based medications with clinical trials and postmortem exams to evaluate therapies. The result was the discovery of germs, the shift away from extreme depletion procedures to let the body heal, and the extraction of usable chemical ingredients from traditional medications that made exact doses possible—quinine from cinchona bark and morphine from opium. No one in Europe entered the profession without academic and government approval.

But 19th century Americans thought themselves different from Europeans. They rejected the advances made in overseas laboratories, hospitals, and medical schools. Doctors had no need of science in medicine. They thought Americans were exceptional, sturdier and better able to handle the traditional heroic methods. Americans did not need numbers to tell them about the best methods or want governmental intrusion into their freedom to choose a therapy.

That attitude finally changed. In the twentieth century Americans began to follow the European lead in training and research. Since then medicine has made extraordinary strides to improve the quality of life, to extend life expectancy from the forties to close to the eighties today. But recently we have been falling behind Europe, not in technology but in outcomes. We have rejected the European model of universal health care in favor of the less effective public-private delivery systems. Obamacare may cover more people than the current system, but we obstinately ignore those programs with better outcomes. Once again we are held back by the belief that Americans are exceptional!

Elaine G. Breslaw is the author of “Lotions, Potions, Pills, and Magic.”

Naomi Campbel Danneel Ackles

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