Imagine that the year is 1755 and you are a patient in Philadelphia’s Pennsylvania Hospital, America’s first hospital. Care at the hospital consists mainly of providing food and rest until the body can heal. You have been feeling better, and one day the doctor asks if you are ready to try some exercise. You agree, and are handed a broom and told to sweep the floor.
Welcome to the early days of health care in America, when patients did much of the work to keep hospitals running. Back then, most health care was provided in the home by family members or servants, with an occasional house call by a physician. But port cities like Philadelphia had people such as sailors, travelers and the homeless who did not have families close by and who sometimes fell ill. The Pennsylvania Hospital was an answer to the problem. Though the hospital provided medical treatment, its operation resembled an old-fashioned almshouse in some ways.
Almshouses began in Europe in the Middle Ages. Usually they were merely a house owned by a church or other charity. It has been written that almshouses provided a “substitute household” for people who were down and out. The people lived as a family, taking care of each other, growing food and doing housework. And what unusual families they were: feeble elderly folk, orphaned children, invalids and mentally ill people all living under one roof.
Able-bodied people, with the exception of church workers who took care of the houses, looked upon  almshouses with distaste. Almshouses were believed to be dirty, disease-ridden and chaotic.
Hospitals in colonial America carried some of the almshouse stigma and people dreaded having to go to them. But physicians and community leaders believed hospitals could become places of healing that would be trusted by the public.
In the 1800s, new hospital buildings were designed to let in more sunlight and fresh air. Cleanliness was promoted. But the public still associated hospitals with death. This was not surprising since some people were in the hospital for months dying of incurable diseases.
Hospital supporters decided that changing the clientele would improve the image of hospitals. So hospitals focused on treating acute diseases (short-term illnesses), which offered better chances of recovery. Patients with hopeless chronic ailments were moved to other locations. Alcoholics and the mentally ill were denied admittance unless their situation offered hope of improvement or where someone was able to pay the bill. The hospitals hired janitors and cooks, and patients no longer had to help in the laundry.
With the advent of anesthesia and sterile surgical procedures in the mid-to-late 1800s, hospitals could at last offer better results than home treatment. In place of the frowzy family atmosphere of former days, the best hospitals in the early 1900s had an air of technical competence that drew respect. Rich and poor patients alike received the best treatments for injuries and acute ailments regardless of their ability to pay. But chronically ill people missed out on some of the medical bounty.
People who were injured or had an acute illness were more likely to have been employed than were chronically ill people. They were more likely to pay something toward the cost of their care. Hospitals still helped the chronically ill, but not enough to meet all needs. So people with chronic mental or physical illnesses and little money were left in the care of local or state governments. Some cities built tax-supported hospitals, but finances and standards of care were typically lower than in privately controlled hospitals. In 1906, one writer reviewed New York City hospitals:
Here, on the one hand, are the public hospitals, Bellevue, City, Metropolitan and Kings County, conducted at an average expense of $1.00 per capita per day or less; and on the other hand a large number of institutions of the highest grade, supported mainly by the gifts of the benevolent and conducted at a daily per capita cost which approximates $2. Throughout the country, in Philadelphia, Cincinnati, St. Paul, Milwaukee, Chicago, St. Louis, San Francisco, New Orleans, etc., contrasts of this sort are found.
Eventually governments learned how to move more chronically ill people back to privately controlled hospitals while basically offering to pay one dollar for two dollars worth of service. In 1965, Medicare expanded insurance for retired people, a group with inadequate care. Though it required subsidies from other hospital users, Medicare could be defended because it kept people healthy and able to stay in their own homes.
Some ideas were less successful. Many mental hospitals were closed, and the former residents were given an apartment, some medicine, counseling and a monthly check. A fair number of mentally ill people were unable to manage their affairs and had repeated admissions to hospitals for minor ailments that had gone untreated. Up to 25% of acute care hospital beds are occupied by people with mental illnesses. The return of patients with physical and mental chronic illnesses to America’s hospital system put strains on hospital budgets and helped send health insurance premiums skyward.
The managers of American hospitals spent 150 years changing from the routine of the medieval almshouse only to discover that the issues the almshouses addressed still existed. It seemed that no amount of money could solve such problems on an acute care basis.
This brief history shows that private efforts created a revolution in health care, and private charity did much good. But it also shows that chronic needs were not sufficiently addressed and governments had a role in fixing the problem. Lately governments have gone too far and forced hospitals to attempt to do the impossible.
Perhaps Americans should begin thinking like a family again—providing modern “substitute households” for people who are unable to live on their own and unable to handle money. People could be offered safe, clean surroundings in return for helping with housework. The predicaments of some clients of today’s hospitals, as with folk in the old-fashioned almshouses, testify that some people need a caring environment instead of a check from the government.

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