The United States of America

Abstract

The health care system in the USA is historically characterised by inequities which especially affected the poor and the elderly. To account for this prior to the landmark of Medicare legislation, one must point to the socio-economic origins and resultant cultural attitudes long dominant in the USA. In addition to the early 19th centure Jeffersonian philosophy that that government governed best which governed least, there were reinforcements from a exuberant laissez faire capitalism. This resulted in a philosophy whose basic tenet was that every man was on his own and that he who could not purchase desirable material goods or medical services had only himself to blame. This viewpoint was strengthened by the numerous examples of the acquisition of wealth afforded by a pioneering and vertically mobile society. In this land of opportunity the poor, both young and old, were regarded as self-generated failures in life’s struggles. It is in this context that one must retrospectively judge the gross inadequacy of medical care and the almost uncountable episodes of man’s inhumanity to man. An example of the latter were the notorious county poorhouses. These were domiciliary structures operated at the ‘pinch-penny’ level, designed for the care of the poor who were generally the disabled elderly. Inmates lived in large dormitories, subsisted on the cheapest food and received negligible medical care. Yet with all of their demeaning features, these were settings thought not unfit for the elderly poor. Because of the well-known associations between aging, chronic illness 86 The United States of America and poverty the aged had always contributed a considerable percentage to the medically indigent population. As financial reserves ran out they fell into the charitable sector of hospital and medical care. The sick elderly thus supplied a hard core to the clinic and the in-hospital ward populations. The wards were traditionally dormitory-like facilities, not uncommonly with one to two dozen patients, if not more. in an open setting. Clinic and ward were in striking contrast to the private offices and private pavilions in which the well-to-do were treated. Essentially this produced a two-tier system of care which was quite characteristic of American medical practice throughout more than the first half of the 20th Century. The tiers were defined by economic considerations; the ability to pay the fee. Needless to say, the well-to-do elderly were able to enjoy private facilities including private psychiatric rather than state mental hospitals.