Public Hospitals—Past, Present, and Future

PUBLIC HOSPITALS—PAST, PRESENT, AND FUTURE FRED ALLISON, JR.* As defined by the National Association of Public Hospitals, a public hospital in the United States is an institution owned by federal, state, or local governments [I]. Facilities operated by organizations for nonprofit purposes, whether by churches or by fraternal organizations, represent a second important category of hospitals. Health maintenance organizations (HMO's) and for-profit hospitals, more recent arrivals on the American scene; i.e., since World War II; constitute a third, increasingly significant and, at times, controversial resources for delivery of inpatient health care. Neither nonprofit nor for-profit hospitals will be the focus of this discussion. Public hospitals have had a significant if not dominant past in caring for the sick in the United States, but they now struggle to survive in the increasingly complex and costly environment of today's society. Their future, in the face ofescalating operating costs; economic recession; and budgetary tightening at local, state, and federal levels; is a cause for genuine concern. In view of substantial changes that are being considered to provide universal access to health care for patient populations within this country that have traditionally relied upon public hospitals for their major source of health care, the struggle by public hospitals to prevail will surely become more intense. Some argue that public hospitals , the "safety net" for the poor in the past, have no justifiable place in either the present or the future as a vehicle for delivery of care in this country. It is helpful to look at their past briefly before surveying the present and attempting to project into the future. Historical Perspective The reality of public hospitals extends at least as far back as sixteenth century England. Prior to that time the great church-controlled abbeys, *Department of Medicine, Vanderbilt University, Metropolitan Nashville General Hospital , Nashville, Tennessee 37210.© 1993 by The University of Chicago. AU rights reserved. 003 1-5982/93/3604-082 1$01 .00 596 Fred Allison, Jr. ¦ Public Hospitah wherein knowledge, great wealth, and other material resources were concentrated, provided almost all of the care for the population of a largely rural England. The church-connected system served the poor and underprivileged, whereas the wealthy few were treated at home. This source of care for the poor by the Church was destroyed by Henry VIII when the Church of England replaced Catholicism as the dominant religion for the British Isles. With the dissolution of the abbeys and their staff, there was a need for a new system to care for the poor. Thus, by default, it fell upon governments of municipalities and counties to furnish medical care as well as food and shelter for the sick, poor, and homeless [I]. It was in this vacuum that public almshouses began to evolve, specifically targeted for care of the poor, the aged, the chronically ill, the permanently disabled, women before and during childbirth, foundlings, orphans, alcoholics, the insane, the feeble-minded, and persons with medical and surgical illnesses. Needless to say, because these individuals were frequently wards of the community, they were not considered socially worthy, and, as a consequence, the surroundings provided were usually inferior to those available to the well-to-do. By providing only minimal resources and support, that is with few if any amenities, it was thought that inmates of almshouses would seek to return to more productive circumstances. Admission to or confinement in an almshouse , even for an illness, was widely regarded as a manifestation of social failure [I]. Almshouses, vividly portrayed by Charles Dickens and lately dramatized by movies and television, were also looked upon as workhouses where inmates provided some form oflabor to pay for their own support. With the settling of America, the almshouse concept was transplanted to the colonies, and the first recorded instance was noted in Henricopolis , Virginia. Henricopolis was probably in the present county of Henrico and near to the city of Richmond. Some forty years later a second almshouse was founded in New Amsterdam (New York City) and the city of Boston followed suit in 1665 [I]. Subsequently, almshouses appeared in almost all of the major East Coast cities, entry points for immigrant poor coming...