law by John Adams. Today, the federally owned Veterans Affairs system is the nation’ s largest health system.”
Ownership patterns in the private sector have also shifted, the study noted. Since the 1980s, investor ownership of many types of healthcare facilities and physician practices has been rising.
“ On the insurance side, whereas third-party payment was dominated by employer-sponsored insurance( ESI) in the post – World War II period, Medicare’ s and Medicaid’ s enactment in the Civil Rights Era, and the Affordable Care Act’ s 2014 implementation have dramatically expanded public coverage. Meanwhile, the tax exemption for ESI continues to provide hidden taxpayer subsidies to private insurers.”
The study concluded that“ over the past century, three overarching trends are evident in the financing and ownership of US health care. First, the tax-financed share of health care spending has soared from 9 % in 1923 to 69 % in 2020. Taxpayer subsidies for private insurance accounted for a growing proportion of these public expenditures, rising from 0 % in the 1920s to nearly a third in recent years.
“ Second, for-profit ownership of health care facilities has increased, with a concomitant decline in public ownership. At present, investor ownership predominates for many types of providers, although a notable exception is community hospitals, which remain mostly not-for-profit.
“ Finally, a decreasing share of physicians are self-employed, and more are employees, although the proportion reporting public employment has fallen. The historical trends we observed have not been accompanied by salubrious results: medical costs continue to soar while administrative inefficiency worsens, even as Americans’ health stagnates— or deteriorates.”
None of that developed in a vacuum. Some of the changes were innovative initiatives to meet real needs. Some were expedients in times of crisis. A good deal of it was, and remains, politics and entrenched interests.
Medicine entered the modern era in the middle 1800s when, within the space of about two decades, anesthesia was developed, the germ theory of infection was clinically proven and sterilization of instruments became accepted. Still, through the turn of the century, care was mostly provided by family and friends, community
Courtesy of Kaiser Permanente Heritage Resources Bettmann
Sidney R. Garfield, MD, and Henry J. Kaiser review designs for three modern Kaiser Permanente hospitals for Walnut Creek, San Francisco and Los Angeles in 1953.
doctors and midwives. Hospitals were mostly run by charitable or religious organizations, or teaching universities.
Many timelines of health insurance start in 1912 when the Progressive Party, under Theodore Roosevelt, endorsed health insurance as part of their broader support for social insurance. But in an article in the Spring 2017 issue of Stanford Medicine magazine, Elizabeth Rosenthal, MD, noted that“ in the 1890s, lumber companies in Tacoma,
American Hospital Association President Dr. Claude Munger explains an insurance chart to first lady Eleanor Roosevelt, 1937. In her“ My Day” column on April 17, 1947, Mrs. Roosevelt wrote,“ It has just been drawn to my attention that the American Medical Association, in a report issued in 1940, admitted that families with incomes of less than $ 3,000 a year could not cover all of their sickness bills without assistance if they had to pay these on the usual fee basis. Almost 70 % of American families had incomes under $ 3,000 in the prosperous year of 1945, when employment was at its height.”
Washington, paid two enterprising doctors 50 cents a month to care for employees. It was perhaps one of the earliest predecessors to the type of employer-based insurance found in the United States today.”
As medical treatments and knowledge improved in the early 20th century, the concept of insurance evolved, Rosenthal wrote.“ The archetype for today’ s insurance plans was developed at Baylor University Medical Center in Dallas, Texas, which was founded in 1903 in a 14-room mansion by the Baptist Church. It is now part of Baylor Scott & White Health, since it merged with another health system in 2013, forming a giant healthcare conglomerate.
“ A devout cattleman provided the initial $ 50,000 in funding to open what was then called the Texas Baptist Memorial Sanitarium,‘ a great humanitarian hospital.’ By the 1920s, more and more Texans were coming for treatment. When Justin Ford Kimball, a lawyer who was Baylor’ s vice president, learned that the hospital was carrying a huge number of unpaid bills, he offered the local teachers’ union a deal. For $ 6 a year, teachers who subscribed were entitled to a 21-day stay in the hospital, all costs included. But there was a deductible. The insurance took effect after a week and covered the full costs of hospitalization, $ 5 a day, which is about $ 105 in 2016 dollars.”
Within a decade, the model spread across the country, Rosenthal related.“ Three million people had signed up by 1939 and the concept had been given a
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