Milestones in Public Health 1700–2013
Milestones in Public Health 1700–2013
| • 1700 to 1800: The United States was experiencing strong industrial growth. Long work hours in unsanitary conditions resulted in massive disease outbreaks. U.S. public health practices targeted reducing epidemics, or large patterns of disease in a population, that impacted the population. Some of the first public health departments were established in urban areas as a result of these epidemics. |
| • 1800 to 1900: Three very important events occurred. In 1842, Britain’s Edwin Chadwick produced the General Report on the Sanitary Condition of the Labouring Population of Great Britain, which is considered one of the most important documents of public health. This report stimulated a similar U.S. survey. In 1854, Britain’s John Snow performed an analysis that determined contaminated water in London was the cause of the cholera epidemic in London. This discovery established a link between the environment and disease. In 1850, Lemuel Shattuck, based on Chadwick’s report and Snow’s activities, developed a state public health law that became the foundation for public health activities. |
| • By 1900 to 1950: In 1920, Charles Winslow defined public health as a focus of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts. • During this period, most states had public health departments that focused on sanitary inspections, disease control, and health education. Throughout the years, public health functions included child immunization programs, health screenings in schools, community health services, substance abuse programs, and sexually transmitted disease control. • In 1923, a vaccine for diphtheria and whooping cough was developed. In 1928, Alexander Fleming discovered penicillin. In 1933, the polio vaccine was developed. In 1946, the National Mental Health Act (NMHA) provided funding for research, prevention, and treatment of mental illness. |
| • 1950 to 1980: In 1950, cigarette smoke is identified as a cause of lung cancer. • In 1952, Dr. Jonas Salk developed the polio vaccine. • The Poison Prevention Packaging Act of 1970 was enacted to prevent children from accidentally ingesting substances. Childproof caps were developed for use on all drugs. In 1980, the eradication of smallpox was announced. |
| • 1980 to 1990: The first recognized cases of AIDS occurred in the United States in the early 1980s. • 1988: The Institute of Medicine Report defined public health as organized community efforts to address the public interest in health by applying scientific and technical knowledge and promote health. The first Healthy People Report (1987) was published that recommended a national prevention strategy. |
| • 1990 to 2000: In 1997, Oregon voters approved a referendum that allowed physicians to assist terminally ill, mentally competent patients to commit suicide. From 1998 to 2006, 292 patients exercised their rights under the law. |
| • 2000s: The second Healthy People Report was published in 2000. The terrorist attack on the United States on September 11, 2001, impacted and expanded the role of public health. The Public Health Security and Bioterrorism Preparedness and Response Act of 2002 provided grants to hospitals and public health organizations to prepare for bioterrorism as a result of September 11, 2001. |
| • 2010: The ACA was passed. Its major goal is to improve the nation’s public health level. The third Healthy People Report was published. |
| • 2013: The ACA provided funding to state Medicaid programs to increase preventive services at little or no cost. |
Disease control and health education were also integral components of public health departments. In 1916, The Johns Hopkins University, one of the most prestigious universities in the world, established the first public health school (Duke University Library, 2013). Winslow’s definition of public health focuses on the prevention of disease, while the IOM defines public health as the organized community effort to protect the public by applying scientific knowledge (IOM, 1988; Winslow, 1920). These definitions are exemplified by the development of several vaccines for whooping cough, polio, smallpox, diphtheria, and the discovery of penicillin. All of these efforts focus on the protection of the public from disease.
The three most important public health achievements are (1) the recognition by the Surgeon General that tobacco use is a health hazard; (2) the number of vaccines that have been developed that have eradicated some diseases and controlled the number of childhood diseases that exist; and (3) early detection programs for blood pressure and heart attacks and smoking cessation programs, which have dramatically reduced the number of deaths in this country (Novick, Morrow, & Mays, 2008).
Assessment, policy development, and assurance, core functions of public health, were developed based on the 1988 report, The Future of Public Health, which indicated there was an attrition of public health activities in protecting the community (IOM, 1988). There was poor collaboration between public health and private medicine, no strong mission statement and weak leadership, and politicized decision making. Assessment was recommended because it focused on the systematic continuous data collection of health issues, which would ensure that public health agencies were vigilant in protecting the public (IOM, 1988; Turnock, 1997). Policy development should also include planning at all health levels, not just federally. Federal agencies should support local health planning (IOM, 1988). Assurance focuses on evaluating any processes that have been put in place to assure that the programs are being implemented appropriately. These core functions will ensure that public health remains focused on the community, has programs in place that are effective, and has an evaluation process in place to ensure that the programs do work (Turnock, 1997).
The Healthy People 2000 report, which started in 1987, was created to implement a new national prevention strategy with three goals: increase life expectancy, reduce health disparities, and increase access to preventive services. Also, three categories of health promotion, health prevention, and preventive services were identified and surveillance activities were emphasized. Healthy People provided a vision to reduce preventable disabilities and death. Target objectives were set throughout the years to measure progress (CDC, 2013a).
The Healthy People 2010 report was released in 2000. The report contained a health promotion and disease prevention focus to identify preventable threats to public health and to set goals to reduce the threats. Nearly 500 objectives were developed according to 28 focus areas. Focus areas ranged from access to care, food safety, education, environmental health, to tobacco and substance abuse. An important component of Healthy People 2010 is the development of an infrastructure to ensure public health services are provided. Infrastructure includes skilled labor, information technology, organizations, and research. In 2010, Healthy People 2020 was released. It contains 1,200 objectives that focus on 42 topic areas. According to the Centers for Disease Control and Prevention (CDC), a smaller set of Healthy People 2020 objectives, called Leading Health Indicators (LHIs), have been targeted to communicate high-priority health issues. (CDC, 2013a). The goals for all of these reports are consistent with the definitions of public health in both Winslow’s and the IOM’s reports.
It is important to mention the impact the terrorist attack on the United States on September 11, 2001, the anthrax attacks, the outbreak of global diseases such as severe acute respiratory syndrome (SARS), and the U.S. natural disaster of Hurricane Katrina had on the scope of public health responsibilities. As a result of these major events, public health has expanded its area of responsibility. The terms “bioterrorism” and “disaster preparedness” have more frequently appeared in public health literature and have become part of strategic planning. The Public Health Security and Bioterrorism Preparedness and Response Act of 2002 provided grants to hospitals and public health organizations to prepare for bioterrorism as a result of September 11, 2001 (CDC, 2009).
Public health is challenged by its very success because the public now takes public health measures for granted: There are several successful vaccines that targeted almost all childhood diseases, tobacco use has decreased significantly, accident prevention has increased, there are safer workplaces because of the Occupational Safety and Health Administration (OSHA), fluoride is added to the public water supply, or there is decreased mortality because of heart attacks (Turnock, 1997). When some major event occurs like anthrax poisoning or a SARS outbreak, people immediately think that public health will automatically control these problems. The public may not realize how much effort, dedication, and research takes place to protect them.
TABLE 1-4 Milestones of the U.S. Health Insurance System 1800–2014
| • 1800 to 1900: Insurance was purchased by individuals like one would purchase car insurance. In 1847, the Massachusetts Health Insurance Co. of Boston was the first insurer to issue “sickness insurance.” In 1853, a French mutual aid society established a prepaid hospital care plan in San Francisco, California. This plan resembles the modern Health Maintenance Organization (HMO). |
| • 1900 to 1920: In 1913, the International Ladies Garment Workers began the first union-provided medical services. The National Convention of Insurance Commissioners drafted the first model for regulation of the health insurance industry. |
| • 1920s: The blueprint for health insurance was established in 1929 when J. F. Kimball began a hospital insurance plan for school teachers at the Baylor University Hospital in Texas. This initiative became the model for Blue Cross plans nationally. The Blue Cross plans were nonprofit and covered only hospital charges so as not to infringe on private physicians’ income. |
| • 1930s: There were discussions regarding the development of a national health insurance program. However, the AMA opposed the move (Raffel & Raffel, 1994). With the Depression and U.S. participation in World War II, the funding required for this type of program was not available. In 1935, President Roosevelt signed the Social Security Act (SSA), which created “old age insurance” to help those of retirement age. In 1936, Vassar College, in New York, was the first college to establish a medical insurance group policy for students. |
| • 1940s to 1950s: The War Labor Board froze wages, forcing employers to offer health insurance to attract potential employees. In 1947, the Blue Cross Commission was established to create a national doctors network. By 1950, 57% of the population had hospital insurance. |
| • 1965: President Johnson signed Medicare and Medicaid programs into law. |
| • 1970s to 1980s: President Nixon signed the HMO Act, which was the predecessor of managed care. In 1982, Medicare proposed paying for hospice or end-of-life care. In 1982, diagnosis related groups (DRGs) and prospective payment guidelines were developed to control insurance reimbursement costs. In 1985, the Consolidated Omnibus Budget Reconciliation Act (COBRA) required employers to offer partially subsidized health coverage to terminated employees. |
| • 1990 to 2000: President Clinton’s Health Security Act proposed a universal healthcare coverage plan, which was never passed. In 1993, the Family Medical Leave Act (FMLA) was enacted, which allowed employees up to 12 weeks of unpaid leave because of family illness. In 1996, the Health Insurance Portability and Accountability Act (HIPAA) was enacted, making it easier to carry health insurance when changing employment. It also increased the confidentiality of patient information. In 1997, the Balanced Budget Act (BBA) was enacted to control the growth of Medicare spending. It also established the State Children’s Health Insurance Program (SCHIP). |
| • 2000: The SCHIP, now known as the Children’s Health Insurance Program (CHIP), was implemented. |
| • 2000: The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act provided some relief from the BBA by providing across-the-board program increases. |
| • 2003: The Medicare Prescription Drug, Improvement, and Modernization Act was passed, which created Medicare Part D, prescription plans for the elderly. |
| • 2006: Massachusetts mandated all residents have health insurance by 2009. |
| • In 2009, President Obama signed the American Recovery and Reinvestment Act (ARRA), which protected health coverage for the unemployed by providing a 65% subsidy for COBRA coverage to make the premiums more affordable. |
| • 2010: The ACA was signed into law, making it illegal for insurance companies to rescind insurance on their sick beneficiaries. Consumers can also appeal coverage claim denials by the insurance companies. Insurance companies are unable to impose lifetime limits on essential benefits. |
| • 2013: As of October 1, individuals can buy qualified health benefits plans from the Health Insurance Marketplaces. If an employer does not offer insurance, effective 2015, consumer can purchase it from the federal Health Insurance Marketplace. |
| • 2014: The ACA requires all individuals to purchase health insurance if they can afford it. |
