Health Care SUMMARY

1. Until around 1900, most Americans received all health care at home. Those who could not care for themselves or obtain care at home were relegated to almshouses—charity institutions with terrible conditions where orphans and criminals, as well as people with illnesses or disabilities, were “warehoused.”

2. Voluntary (nonprofit private) hospitals first emerged in the late 1700s as a means of providing care to the “deserving sick.” Early voluntary hospitals were run as total institutions. Hospital conditions improved dramatically during the Civil War and improved further as the new belief in germs made cleanliness desirable and technological changes made it economically feasible.

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3. For-profit, private hospitals emerged as a way of offering better conditions to more affluent consumers. Public hospitals were developed to provide services to individuals with chronic mental or physical illnesses as well as to those considered the “undeserving poor.” By the 1920s, hospital care had become a major part of American life and a center of medical education and research.

4. The initiation of Medicare and Medicaid dramatically increased the profits available to hospitals. Skyrocketing costs led the federal government to implement a system of diagnostic-related groups, under which hospitals receive a prepaid fee for each patient with a given diagnosis, regardless of the actual cost of treatment. To maintain their profits, hospitals shifted toward remunerative outpatient services, technologies, and surgeries.

5. Hospitals now treat an older and more seriously ill mix of patients than in the past, primarily for the acute complications of chronic illnesses. Hospitals—especially public hospitals—have become primary care providers for the poor, which has increased hospitals’ financial problems.

6. Nursing homes offer care to those who need nursing or custodial care but not hospital care. Those who use nursing homes tend to be female and elderly, although young people increasingly live in nursing homes. Most residents and their spouses are bankrupted quickly by the cost of care.

7. Nursing homes are primarily staffed by nursing assistants, who are overwhelmingly female, nonwhite, and low paid. Within nursing homes,

both nursing assistants and residents are commodified: Nursing assistants become commodities to purchase as cheaply as possible, and residents become expenses to control.

8. Hospices are institutions designed to serve the needs of the dying. To gain social and financial support, hospices have increasingly become routinized, medicalized, and focused on profit making.