How did healthcare work in America 50-75 years ago?

Great Debates
1

Everyone knows that healthcare in the U.S. right now is really convoluted and almost no one appears to be happy with the system, except perhaps for the few with truly amazing plans (a group I have little to no contact with).

I was chatting with some younger doctors just finishing their fellowships in Internal Medicine subspecialties (the lower paying ones, like rheum, endo, ID) who said they expected to need to see at least 25 patients/day to make ends meet. An older doctor (I would say at least in his 70s) chimed in that when he was in private practice (let’s say 20-30 years ago, maybe longer) he would see 2 new and 10 old pts a day. He also said that 20% of his practice was gratis for indigent patients, and that poor people back then did not want for health care. I have often heard many older physicians remark that they needed to see relatively few patients decades ago, but they seem to have been reimbursed more.

So how did this system work? Did a large chunk of its feasibility rely on the fact that your primary expense back in the days before expensive imaging and procedures was simple doctors’ fees, so that everyone (except the indigent) paid the equivalent of $100 to see the doc, but not much more?

I would be really interested to know what healthcare was like back then. Maybe that knowledge could be used to shed insights onto how to deal with our current healthcare woes.

2

I think that is part of it, but I also think that costs for doctors have risen astronomically since then. I know malpractice insurance is a huge cost for most doctors, and it seems that the amount of support staff has gone up hugely as well- as a boy in the 1970s, my doctor had maybe a couple of nurses and an admin. Now it seems that a doctor has half a dozen nurses and several admin people on staff, as well as a whole lot more specialized equipment- ultrasound machines, all sorts of software, etc… Gone are the days when a Dr. really only needed a syringe, a blood pressure cuff, a stethoscope and that gizmo to look in your throat and ears.

Add all those things up, and combine with the fact that insurance companies frequently pay far less per patient than a non-insured walk-in would pay, and you have the recipe for doctors having to see more and more patients per day to make ends meet / hit their target income.

3

I know this is a lot further back than you’re asking, but Mark Twain in his autobiography talks about how his family would pay a certain dollar value for a year’s worth of medical care, and the doctor would make unlimited visits. Thus it was incumbent on the doctor to keep his patients healthy, or else his costs would outstrip his income.

4

A large part of how healthcare worked was that everybody had far lower expectations. There were no organ transplants, no joint replacements, few vaccines, little internal imaging, far fewer effective medicines, etc. Everybody knew that some things neither a doctor nor a hospital could help you with.
When I was 12, a family friend who was about the same age as my grandparents had a heart attack. He stayed up all night in severe pain. Finally, about 12 hours or so after the symptoms began, his sisters finally convinced him to go to the hospital.

I asked my Grandma why he didn’t go right away. She told me, “When we were your age, people didn’t go to the hospital to get well. They went to the hospital to die.”

That helped me to understand how enormously healthcare has improved in the last several decades.

5

By today’s standards? It didn’t.

6

In the sixties, just about every full time job gave you health insurance at no cost to you. It was an 80/20 policy with a deductible. They paid 80 percent and you paid 20. The policies had lots of exclusions - pregnancies were generally not covered so folks had to pay the obgyn and hospital bills themselves, and they were able to afford it. An office call was about 20 bucks if you were uninsured. Prescriptions were not covered. As I recall, laboratory tests were not covered unless you were hospitalized. But then, being in the hospital cost considerably less than 100 dollars a day.

7

Low technology is not as expensive as high technology. But the difference is that we don’t demand that everyone has the best computer or the best features in their cars or the best HDTV.

But when it comes to healthcare, we don’t say that poor person X gets “regular” health care, but person Y gets the latest and greatest. We want EVERYONE to get the latest and greatest. That presents a problem because just like putting everyone in an oceanfront mansion with premium cable and driving a Lexus SUV, it’s tough to pay for health care for everyone with up to date, best of the best, health care.

8

Medical care used to cost a lot less because there was less of it. They were’t performing quadrupal bypasses and implanting artifical hips. There weren’t a lot of high priced drugs. Doctors were virtually immune from malpractice suits because they wouldn’t testify against another doctor, so malpractice insurance was inexpensive. And as a result health insurance didn’t cost as cost as much either.

9

In the early sixties, my sister was hit in the forehead by a stone kick up by a passing truck, receiving a depressed skull fracture. This was well within the ability of the medical technology of the day to fix, and she was fine, aside from having to wear a football helmet for six months (mortifying to a fourth-grader).

The interesting thing was that the doctor asked my parents if they had insurance. When they replied in the affirmative, he told them that their bill had just doubled.
This is interesting in a couple of ways: first, it is clear that being insured was the exception rather than the rule, second, that the cost of the treatment was within the realm of possibility for a lower middle-class lfamily, and third, that, even then, insurance distorted the market for health care.
Crafting an insurance system that provides for emergencies without providing perverse incentives is very tricky, and we have clearly failed to do any better in the fifty years since. If I were asked to do so, I would suggest that we treat medical insurance as any other insurance, something designed to address unexpected major expenses. Having it cover routine and manageable costs inevitably leads to unrestrained inflation of costs.

10

Back then people would actually have “accounts” with their doctor and pay them off a little at a time. My mother, who was a nurse back then, noted that the doctor bill was often pretty low on the list of things to be paid when money was tight. Since doctors didn’t want to cut off treatment, they ended up carrying a significant number of patients and eventually writing off a chunk of that.

11

Fifty years ago, the insurance we had did NOT cover: Birth control, well baby and child care, annual physicals and checkups, doctor visits for illness. Yes, that last is correct. If your kid got sick enough to see a doctor, but not sick enough to go to the hospital, nothing was covered by insurance. In my first child’s second year we averaged at least one doctor visit per month for earache and/or sore throat that had to be tested for strep.

Fifty years ago dental insurance was rare. Seventy-five years ago it didn’t exist. My parents and dentist decided not to fill cavities in my molars because they (the teeth, not the parents and dentist) were due to fall out soon and it would not be worth the money it would cost. They didn’t fall out on schedule. They sat there and eventually got infected, one at a time, and had to be pulled. The first dental insurance I had was when I got a job in the 80s for a health-related non-profit organization.

As was said earlier, 75 years ago you did not have organ transplants, artificial heart valves, artificial joints, coronary bypass, CAT scans, MRIs, and a host of other things. Surgery was about the only treatment for cancer (I may be wrong about that.) Heck, 50 years ago they didn’t have ibuprofen. You could take aspirin or Midol for your menstrual cramps and just deal with it.

I don’t know how my parents handled medical bills, but as an adult I generally paid doctors last if I had more bills than money. The doctor, after all, can’t reposess your penicillin or put a lein on your blood.

Yes, I imagine there are more malpractice suits today. I really don’t have a problem with it if it’s not frivolous. My dad was slowly recovering from a near-fatal auto accident when I was a pre-schooler. He also contracted hepatitis while in the hospital. I don’t think my parents even thought of suing the hospital. By that time, all of the hospital staff were like family to them. Perhaps they should have, though. There apparently were not disposable syringes then, and he almost certainly got the hepatitis through a not completely sterile needle.

We did have to deal with measles, mumps, chicken pox, the fear of polio and a lot of other things that are now possible to prevent with vaccines. We did NOT have to worry about AIDS, though.

12

In some parts of the world private health care while not cheap is well within the grasp of the average person, procedures that would be outrageously expensive in the USA without insurance are a couple hundred dollars. New drugs are expensive, you need to decide if you are willing to pay for it or maybe try a cheaper alternative.
While some drugs require a prescription, it isn’t the majority and very many are dispensed by pharmacists, which also eases a bit of the burden of cost.

Doctors and surgeons are a bit more of technicians in that sense, they tell you the options and what it will cost. I would never have dental work done in the USA, the cost is outlandish and the focus seems to be on cosmetics and upsells. Nothing has advanced in the field of filling cavities, why pay for nothing?

13

It still happens. Some doctors will automatically cut their fee in half for someone who doesn’t have insurance. I know about case exactly like that. But that’s a doctors fee. If you need a quadruple bypass, the doctor’s fee is a small part of the total bill.

14

Apparently, here in Nevada you just gave the doctor a chicken.

15

One thing I learned from my parents, both of whom were born in the late 1930s: my father’s father was a bank official. His employer did not provide health insurance. My mother’s father worked in a factory. His employer did. Why, because the factory had a trade union which demanded it.

I don’t know if that was universally true, but I thought it was interesting.