toon-1079Now where were we? Oh yeah: the important thing was I had an onion on my belt, which was the style at the time. They didn’t have white onions because of the war. The only thing you could get was those big yellow ones…

Grandpa Simpson, Last Exit to Springfield

One of the persistent myths of my profession is that “we used to see whoever needed to be seen, regardless of whether or not they could pay.” Then came Guv’mint and, well, you know the rest. The slippery slope to communism. The beauty of these myths is that they are very difficult to contradict. A pure market system last existed long ago in this country. Private insurance started in 1950, and though it initially covered hospital care only, it quickly added coverage for office visits. Kerr-Mills began providing care for the poor in the 1950s and was followed by Medicare and Medicaid in the 1960s. Those who fondly recall the days of sliding physicians fees  are by now in their 70s and 80s and are mostly recalling childhood visits (remember the smell of rubbing alcohol?).

In 1950, the first year for which we have good data, the average American at birth could expect to spend 68 years on this earth (65 for guys and 71 for gals). If that person happened to be black, as about a third of Alabamians were, those numbers were a bit less (59 for men and 62 for women). These numbers mostly reflect deaths in childhood, because those that were already 65 could expect to live another 14 years (or almost to age 80) and the difference between races was non-existent.  Access to good sanitation and immunizations was the difference in getting kids to age 5. Access to physicians, not so much.

The other thing that we know is that prior to our current patchwork system, the medical problems in young, healthy 20 year-olds were, well, a problem. From a 1951 article entitled Physical Status of Men Examined Through the Selective Service in World War II we find that 40% of men over 18 examined for selective service in Alabama were disqualified. 19% of those disqualified were for dental problems. You had to have 12 (TWELVE) teeth, 6 on top and 6 on bottom, to be qualified for service. 30% didn’t have vision corrected to 20/40 or better (THEY HAD NO GLASSES). 1 in every 8 had gonorrhea or syphilis. 1 in 100 had ACTIVE tuberculosis. In the discussion, the author point out that children reared in a North Carolina orphanage who had good access to health care paid for by someone other than their parents only had 1.4% rejects. Recruits from the general North Carolina population with limited access to health care  had a 44% rejection rate. While the AMA was urging us to protect our patients from the federal government,  this physician was making an argument for improved access through government action.

Fast forward 60 years. We have provided almost all citizens access to sanitation and immunizations and most to access to care prior to birth (and now prior to conception in those states accepting the Medicaid expansion). Life expectancy at birth is now almost 79 years and those that are 65 can expect to make 84. Tuberculosis is a disease of the past. Most of us have multiples of 12 teeth. Almost all of us that can see do see. Though disparities still remain, much has improved thanks to Medicare, Medicaid, and subsidized insurance. When physicians wax nostalgically about the days before “big guv’ment” I tend to think about them with an onion on their belt.