History and Organization of the Health Care System (1)

Colonial era health care (early U.S.)

What the system looked like…

• Little support from England, few physicians, poor/under-developed areas

• Survival was the priority

Colonial era health care (early U.S.)

Public health problems (why infectious disease was common)

• No food safety safeguards

• No sewers

• No municipal water authority

• Result: malnutrition + dysentery

Colonial era health care (early U.S.)

Medications + providers of care

• Meds were mostly physician-compounded

• Mix of native remedies + medicines from England

• Few apothecaries (early pharmacists)

• Care provided by friends/family, clergy, and midwives

1800s: Social class & where care happened

Wealth =

health

1800s: Social class & where care happened

• Social class/wealth strongly influenced:

• Living conditions

• Access to health care

1800s: Social class & where care happened

• Poor in urban areas:

• Wealthy:

• Rural

• Rural meds:

• Poor in urban areas: smoky, crowded, poor sanitation

• Wealthy: better living conditions + could afford health care

• Rural: care mostly from family/friends + a few country doctors

• Rural meds: proprietary/patent medicines from traveling “medicine men”

1800s: Social class & where care happened

First licensed pharmacist practiced in…

New Orleans (licensed by Spain) in 1769

Hospitals 1850–1900 + impact of war

What hospitals were like then…

• Wealthy were treated at home

• Hospitals were mostly for poor people and were seen as a place to die

• Hospital technology increases 1870–1900, driven by Civil War experiences

Hospitals 1850–1900 + impact of war

Why war accelerates medical progress (core logic)

• War → practitioners get massive clinical exposure

• They see what works, research becomes a priority

• Shows benefit of prompt medical attention

• After major wars, practitioners advocate for more hospitals (Civil War, WWI, WWII)

Major disease theories in the 1800s

• Contagion theory: isolate/quarantine the sick

• Supernatural cause: illness as punishment from God

• Miasma theory: disease from “bad air”/foul odors

What theory changed everything?

Germ theory-Specific microorganisms cause disease

Germ Theory Championed by…

Pasteur and Lister (1860s)

Germ Theory

• Hospitals shift:

• No longer “place to die”

• Aseptic technique reduces spread

• Physicians can save lives → start bringing in paying patients

Fee-for-service era problems

• Health care was fee-for-service

• Only rich regularly used physicians

• Working class used home remedies to save money

Pharmacy role shifts

• Rise of…

manufactured medications

Pharmacist shifts from…

compounder → retailer of prepared meds

What occurred (historically)?

“Counter-prescribing”, sometimes with cocaine/opium in products

Pharmacy role shifts

Major safety gaps:

• Unlabeled contents

• No discussion of drug–disease, drug–drug, drug–food interactions

• No regulation of preparations/distribution

Pharmacy role shifts

Who were was common?

• Quackery (unqualified “healers”) was common → damages trust → pushes need for regulation + trained professionals

What “professionalism movement” means…

• Formally trained professionals sought:

  • Job/status protection

  • Public trust

  • Licensing + self-regulation

• Competing against quacks/healers without formal training

→ influences pharmacy

• Flexner Report (1910) reshaped medical education:

  • National accreditation

  • Restrict class sizes / graduate fewer students

  • Close weaker schools

Progression of pharmacy education (timeline you should memorize)

• Late 1800s: apprentice model criticized

• By 1900: 53 colleges of pharmacy

• Today: ~145 ACPE-recognized schools (prof said it may be shifting recently)

• Training requirements became more rigorous:

  • Pre-1932: high school graduation

  • 1932: 4 years of college study

  • 1962: 5-year bachelor’s

  • 1960s → present: adds clinical component

  • PharmD: only professional degree since 2004

  • If graduated before 2004: grandfathered (could practice under older degree)

 

Famous people in pharmacy (historical anchors)

• William Procter Jr.: “Father of American Pharmacy”; wrote early American pharmacy textbook Practical Pharmacy (1849); advocated for creation of the American Pharmaceutical Association (now APhA).

• Hubert Humphrey: pharmacist → major politician; co-sponsored Durham–Humphrey Amendment; VP candidate (1964); ran for president multiple times.

• John Pemberton: pharmacist; injured in Civil War; created morphine-free elixir → later marketed as a soft drink (Coca-Cola origin story).

 

Pharmaceutical care

 pharmacist–patient relationship where the pharmacist accepts responsibility for drug therapy outcomes and provides services guided by commitment to the patient’s interests.

“Heart” of educational reform:

“The heart” = Pharmaceutical care

• pushes more clinical training → supports the PharmD-only era.

Regulation shapes pharmacy practice

Pure Food and Drug Act (1906)

Harrison Narcotics Tax Act (1914)

Food, Drug, and Cosmetic Act (1938)

Pure Food and Drug Act (1906)

• Triggered by public outrage about unsafe food/meds (ex: The Jungle)

• Requires drugs are not adulterated and not misbranded

• Helps establish what becomes the FDA

Harrison Narcotics Tax Act (1914)

• Regulates/taxes production/import/distribution of opiates and coca products

• Goal: reduce narcotic use

Food, Drug, and Cosmetic Act (1938)

• Prompted by deaths from unsafe drug product (sulfanilamide elixir tragedy)

• Key shift: drugs in interstate commerce must be SAFE

• Becomes the “base” law that later changes come as amendments

Key amendments (memorize the “what changed”)

• Durham–Humphrey (1951):

  • Creates Prescription (“Legend”) vs OTC classes

• Kefauver–Harris (1962):

  • Triggered by thalidomide disaster

  • Drugs must be SAFE AND EFFECTIVE

• Hatch–Waxman (1984):

  • Encourages generic drug manufacturing

  • Builds modern generic regulation system

“Big list” of policies to know

• Hill-Burton (1946)

• Medicare/Medicaid (1965)

• HMO Act (1973)

• S-CHIP (1997)

• Medicare Modernization (2003)

• ACA (2010)

Hill-Burton (1946)

• Government money to build hospitals, especially improving capacity after WWII

Medicare vs Medicaid (DO NOT MIX)

Medicare

• Federal insurance

• For elderly + long-term disability

• Parts:

  • A: inpatient, SNF, home health, hospice

  • B: outpatient + DME

  • D: prescription drugs (added later)

Medicaid

• For low-income / financially disadvantaged

• Funded by federal + state

• Run by states (rules vary by state)

Private insurance growth (why it exploded)

WWII era tax policy → employers offered insurance → more third-party payment

HMO Act (1973) / Managed care

• Core idea of managed care: control/“manage” costs and utilization

• Federally qualified HMOs had to offer comprehensive benefits at same/lower cost than traditional insurance

CHIP / S-CHIP (1997)

• Coverage for children in families who make too much for Medicaid but still need help

Affordable Care Act (ACA) – what you need

• Created/expanded:

  • insurance exchanges

  • tax credits/subsidies (concept)

  • Medicaid expansion (but states have discretion after court decisions)

• Key idea: reduce uninsured + improve access (but U.S. still spends a lot)