June 28, 2012 --
Today the Supreme Court upheld the 2010 health care law in a dramatic victory for President Barack Obama. The lead up to today's decision has prompted debate between opponents and supporters of the Patient Protection and Affordable Care Act two years ago. Take a look at how we got to the health care system we have in place today.
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Prior to the 20th century, nothing even close to what could be called a health care system existed in the United States. Although the Civil War had led to some medical breakthroughs in terms of surgical techniques and pain management, medical knowledge, techniques and treatment availability at the time left little hope that patients would actually recover from severe ailments. As NPR's Alex Blumberg and Adam Davidson point out, medical treatments may have been downright medieval at the time, consisting of potions. But at least it was cheap. "In 1900, the average American spent $5 a year on health care ($100 in today's money)," they note in their report.
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In 1912, Theodore Roosevelt was the first presidential candidate to get behind the idea of a national health insurance plan. Roosevelt ultimately didn't win election that year. Proponents of government-provided health care tried to press the issue through state initiatives, only to see their efforts fail in 16 states. Roosevelt's plan may have certainly been ahead of its time, particularly since there weren't that many services that doctors could actually provide patients during that era.
At the same time, however, developments within the medical community changed the face of the industry. The horrors of World War I led to advances in the areas of wound care, sanitation, pain management and more, according to an article published in the Journal of the Royal Society of Medicine. Hospitals in the United States began to widely adopt the practice of using antiseptics to sanitize their facilities, preventing the possibility of medical personnel or patients becoming exposed to infection. That decade also saw the introduction of the first employer group insurance contracts (though not specifically for health insurance) as well as the first physician service and industrial health plans.
In 1928, Alexander Fleming made one of the most important discoveries in the history of medicine: penicillin, a life-saving drug used to treat countless millions. It would be decades, however, before penicillin would be mass-produced. Fleming's discovery was the signature achievement in an era that saw medical treatment become more effective, and, as a result, expensive. The Great Depression also fueled concerns about affordability of medical treatment as millions of Americans suddenly found themselves out of work. In 1929, Baylor Hospital provided the first group health insurance plan in the United States through an agreement with Dallas-area teachers. The plan was the forerunner of Blue Cross. The effort wasn't just meant to be in the best interests of patients, but also the hospitals. Patient facilities saw more empty beds as fewer patients during the Great Depression could afford treatment without participating in these collective prepaid health insurance plans.
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As part of his push to create a social safety net for Americans during the Great Depression, President Franklin D. Roosevelt advocated the passage of national health insurance. Roosevelt pushed ahead with efforts to pass Social Security first, a bill which intentionally omitted any mention of medical care to ensure its passage. Harry Truman attempted to carry on Roosevelt's legacy in 1945 by calling on Congress to create such a program. His efforts failed, partly due to criticism by the American Medical Association (AMA), who called the plan "socialized medicine." In this photo taken in 1937, First Lady Eleanor Roosevelt examines a chart of enrollment of health care insurance plans.
Like its predecessor, World War II would lead to new medical advancements, including the widespread adoption of antibiotics and the use of ultrasound. The war would also have a similar effect in terms of the spread of employer-sponsored health plans. Because the nation was in a state of emergency and had a legally mandated wage freeze as a result, employers had to attract workers to assist the war effort by providing them with benefits, including health insurance. Tax laws passed between 1943 and 1945 also gave breaks to employers who provided insurance to their employees, which gave businesses all the more incentive to offer coverage. Following the war, employer-sponsored health insurance became common. In 1951, around 77 million Americans had some kind of coverage, according to an insurance industry trade group. That era also saw one of the most celebrated medical achievements in history: Jonas Salk's polio vaccine.
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Although health insurance was widely available to employed Americans in the mid-20th century, the unemployed and the elderly were often excluded from these plans. President John F. Kennedy campaigned on the issue of insuring these groups. President Lyndon B. Johnson succeeded where Kennedy left off, securing the passage of a bill through Congress creating Medicare and Medicaid. At the bill-signing ceremony, shown here, Johnson presented former president Truman with the nation's first Medicare card. Within the medical industry itself, an increasing number of doctors began specializing in certain fields of medicine rather than acting as general physicians. By 1960, more than two-thirds of doctors reported themselves as full-time specialists, rather than general practitioners.
Starting with Richard Nixon in 1970, presidents have offered successive plans for covering the nation's uninsured, but they have have stalled for different reasons. In 1974, Nixon put forward a plan to cover all Americans through private insurance, only to have the Watergate scandal force him out of office. An economic crisis prevented Jimmy Carter from pushing forward with a national health plan. Congress late in Reagan's second term attempted to expand Medicare, only to have the law repealed the following year. Bill Clinton had a 1,300-page health care reform bill that was never even taken up for a vote in Congress. Since Nixon's presidency, health care costs have continued to rise, often outpacing inflation. This increase is due to a number of factors, including the increased use of new medical technologies for diagnosis and treatment. The Patient Protection and Affordable Care Act signed by President Barack Obama was intended to cover the 30 million Americans who live without health insurance, according to the bill's authors. It has been the most far-reaching piece of health care legislation since Johnson's signed the legislation creating the Medicare and Medicaid health care programs.
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Two weeks into the government shutdown, flu season is about to ramp up. And without full-scale infectious-disease surveillance by the Centers for Disease Control and Prevention, experts said, health consequences for the nation could range from unsettling to disastrous.
Normally, the CDC monitors influenza outbreaks across state lines. The agency continually analyzes circulating strains to detect the potential for brewing pandemics. And if there is any sign that a mutant virus is particularly virulent or has developed resistance to antiviral drugs, the CDC spreads targeted public health messages, develops new vaccines or takes other actions.
Now, little of that real-time vigilance is happening. The website that usually reports state-by-state cases, hospitalizations and deaths from the flu has not been updated since the shutdown began.
“Without CDC activity, which analyzes all of the information and feeds it back to everyone who needs to know, we’re flying blind,” said William Schaffner, an infectious disease specialist at Vanderbilt University’s School of Medicine in Nashville. “The government may be closed. But the virus is not.”
Every year, the fight against the flu begins many months before the virus begins its annual march through the population, starting as early as October. By closely watching which strains are circulating around the world from month to month, the CDC leads the way in developing a seasonal vaccine that aims to protect people from what is predicted to be spreading through schools and workplaces all winter long.
So far, this year’s vaccine appears to be a good match to the virus that is just beginning to infect people around the United States. And there's plenty of vaccine to go around.
But it’s still extremely early in the season, and influenza is a volatile family of viruses that change constantly. Without notice, a new strain can become especially infectious and spread rapidly -- a risk that increases as the season wears on.
“If there’s one thing I’ve learned in 30 years of working with this, it’s that it’s a fickle, fickle virus,” said Greg Poland, director of the Mayo Clinic's Vaccine Research Group in Rochester, Minn. “It’s the unpredictability of this illness that requires worldwide monitoring.”
When the CDC is up and running, Schaffner said, it's like the conductor of a finely coordinated influenza orchestra. Monitoring of the number and severity of illnesses begins at the local and state level, but all of that data gets sent to the CDC, which looks for alarming patterns or signs of emerging pandemics.
That happened in 2009, when an outbreak of H1N1 swine flu prompted the CDC to develop and promote an additional vaccine. Last year, the agency noticed severe pockets of influenza in specific parts of the country, which helped it target public health messages and resources.
“Anything can happen,” Schaffner said. “That’s why you need that constant surveillance.”
And it’s not just the flu that has the potential to cause major problems during the current shutdown. The CDC plays an essential role in monitoring infectious diseases like measles and polio, as well as foodborne pathogens, like an ongoing salmonella outbreak that has sickened hundreds of people around the country. Careful surveillance is the only way to link cases in different states or countries as the same emerging problem.
The federal government is also responsible for conducting routine inspections of high-security labs that investigate extremely dangerous pathogens like ebola viruses.
Without a full staff at work, the potential for health crises to develop will only escalate.
The CDC has “furloughed two-thirds of their employees and only have 4,000 people working -- that’s a skeleton crew,” Poland said. “It does put the nation at some risk.”