Timeline: History of changes (and battles) in American healthcare

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As Republicans seek to dismantle the Affordable Care Act and possibly force a vote on a replacement plan, Americans are witnessing the most recent debate in a long history of clashes over access to healthcare and how medical services are delivered.

Here’s a short – but by no means exhaustive – timeline of America’s healthcare system based largely on the work of Michael Morrisey, a health insurance scholar at Texas A&M University.

1756 – College of Philadelphia (now the University of Pennsylvania) offers first medical training in the colonies.

1847 – American Medical Association founded to improve education. But until science progressed in the next century, hospitals were often viewed as places to die.

1900 – Under common law, employers were liable for injuries that occurred at their facilities if the employer was negligent, but health insurance did not exist.

1910-1915 – Some 32 states enacted workers' compensation insurance as workers' rights advocates saw the reforms as a means to shift the costs of workplace injuries to the employer and hold companies more accountable. Employers also viewed the reforms as a way to reduce the legal costs associated with negligence claims reduce overall costs.

Organized medicine supported the workers’ compensation legislation because injured workers would likely go to their family doctor for care and the doctor would be paid by the workers’ compensation fund. Instead, employers began to directly retain and sometimes employ physicians and offer care in industries like mining and lumber. As a result, local physicians saw a reduction in the demand for services.

1916-1919 – States considered compulsory health plans based on a workers' compensation model, but both labor unions and employers and the AMA either had mixed views or were opposed the idea.

1929-1930 – At the onset of the Great Depression, Baylor University Hospital, then in Dallas, devised a system for people to pay for hospital care and enrolled 1,250 Dallas public school teachers in the Baylor Plan. For 50 cents a month, the plan promised to provide 21 days of care in the hospital. By 1933, 26 such "hospital service plans" were in existence.

1933 – The American Hospital Association (AHA) established its Committee on Hospital Service in 1933 and began approving plans. This committee became the AHA Hospital Service Plan Commission in 1936 and the AHA Blue Cross Commission in 1946. The Blue Cross Commission granted exclusive geographic market areas to each approved plan. 

1934 – Commercial carriers began offering hospital coverage. Initially, they did not cover physician coverage, but they did offer surgical coverage, beginning in 1938.

1937 – President Roosevelt convenes a Technical Committee on Medical Care to advance health reform.

1939 – The development of Blue Shield plans mirror that of Blue Cross. The first medical service plan, the California Physicians' Service, was established. The plans required free choice of physician, they were indemnity rather than service benefit plans.

A number of pre-paid group practice plans had already come into existence for various groups of employees. This type of private health coverage continued to grow, but on the eve of World War II, only 9 percent of Americans were covered by some form of private health insurance.

1947 – World War II saw a rapid growth of the insured as companies offered health insurance to attract workers in a scarce labor environment. Another reason for the rapid growth in health insurance was the expansion of organized labor. Union influence on health insurance stemmed in part from the 1947 Taft-Hartley Act, which defined health insurance as a condition of employment and, subject to collective bargaining. By 1950 more than half of Americans had some form of private health insurance.

1965 – Medicare was introduced as a single-payer health insurance for Americans 65 and older as well as some younger people with certain disabilities.

1966 – Medicaid introduced to provide coverage for lower income adults, children and people with certain disabilities.

1970s – Through the 1960s and into the 1970s, commercial insurers attracted the lowest-cost health subscribers which left community-rated Blue Cross and Blue Shield plans with high-cost subscribers.

1980s – Rapidly rising costs due to technology and inflation coupled with more people seeking healthcare brought the emergence of managed care. The era continues today for about 60 percent of Americans who receive health insurance through employer-sponsored plans such as a health maintenance organization (HMO) or preferred provider organization (PPO).

1993 – President Bill Clinton introduces Health Security Plan, which fizzled in 1994.

2010 – The patient Protection and Affordable Care Act signed by President Barack Obama expanded insurance coverage to more Americans, removed lifetime caps on claims, and made coverage available to those with pre-existing conditions in most cases. By 2016 the uninsured rate of Americans dipped under 9 percent, the lowest in decades and a reversal from just the 9 percent who had any type of healthcare coverage before World War II.

Additional source: Henry J. Kaiser Family Foundation

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