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How the U.S. Health Care System Came to Be

An interview with Ira Rutkow, author of <i>Seeking the Cure: A History of Medicine in America</i>

You and I can probably agree that hemorrhoids don’t cause arthritis. Or tuberculosis, or even eczema.

But try telling Edwin Hartley Pratt that. The 19th-century physician and pioneer of “orificial surgery” convinced thousands of followers that smooth body cavities would cure a host of maladies, providing a life full of “uninterrupted delights.”

Pratt is just one of many physicians who make us giggle or cringe today, yet whose theories played an important role in the development of modern medical treatments. In Seeking the Cure: A History of Medicine in America, author Ira Rutkow invites us to sit in the observation gallery for medical procedures from Colonial America to today. We watch doctors examine President James Garfield’s gunshot wound, treat Houdini’s burst appendix and transplant a kidney between identical twins for the first time.

The book reads like our country’s own personal medical chart. Rutkow, a historian and retired surgeon, traces how doctors went from being poorly respected “bleeders” to the often-revered professionals they are today; how hospitals evolved from unsanitary death traps to state-of-the-art lifesaving institutions; and, ultimately, how medicine transformed into the multibillion-dollar industry that now consumes so much political energy—and so much of our money.

Rutkow shared some of his perspectives behind the book with us, from physicians’ true feelings about Medicare to the importance of having a doctor in the family.

(Read an excerpt here.)

Q. Did any stories especially impress you in your research?

A. All the stories impressed me, because I wanted to write about the most interesting ones. The opening story about Zabdiel Boylston’s smallpox vaccine, the development of anesthesia, orificial surgery, Houdini’s appendicitis—they are all just wonderful.

Q. When President James Garfield was shot in 1881, you write, it wasn’t the bullet that killed him, but infection from doctors who examined his wound with unwashed hands. This was at the height of the germ-theory controversy?

A. Absolutely, but it didn’t help him a whole lot.

Q. Why not?

A. In Garfield’s case, the younger 30-year-old and 40-year-old doctors were pretty much adamant about the fact that these new ideas about bacteria and germs—washing hands, cleaning instruments, keeping things antiseptic—were valid concepts. The older doctors pooh-poohed germ theory. But of course when the president of the United States gets shot, it’s very unlikely that he’s going to be treated by a 30-year-old. He’s going to be treated by the older, more professorial doctors.

Q. How many times did one doctor or another probe Garfield’s wound with a dirty finger?

A. In my research I found between 12 and 15 instances, but I’m sure there are many times that it happened and no one noticed. It was a very sad thing. If Garfield had been left alone he probably would have survived; if he had been shot 10 years later, he probably would have survived.

Q. Because the gunshot itself inflicted a minor wound?

A. In my book on Garfield I compared his assassination with the attempt on Ronald Reagan: If Reagan had been shot in 1881, the bullet’s location would have killed him in six hours. If Garfield’s bullet had hit its location in 1981, he would have been out of the hospital within 24 hours, back at the White House, with no problems.

Q. Stories like this involve doctors fighting new ideas that today we accept as basic medical fact. Why?

A. Without a doubt, doctors are a conservative group, and they don’t take well to newfangled ideas. Older doctors fought germ theory tooth and nail. They couldn’t believe it, and yet this is a theory that is on the same magnitude with what Copernicus did, saying that the Earth rotates around the sun. People fought it for decades and yet it is accepted today as fact, as it should be.

Q. What new medical ideas are facing public resistance right now?

A. Today’s problems regard the finances of health care. I don’t know whether President Obama’s health care package is going to work or not, but clearly there is resistance all over the place. The fact is that science continues to advance. The problem is that our economics and ability to get health care to everybody doesn’t advance as quickly as the science.

Q. What did you learn about health care today in your research?

A. When Medicare was being developed in 1965, the American Medical Association fought it. Members were rather underhanded in some of the things that they did: They promised mayhem would strike the American public in terms of the availability of care, and some doctors even threatened violence. Three years later, doctors loved Medicare, and there’s a reason why.

Q. Why?

A. All of a sudden they got these large payments, which always came on time, and the system was working, much to their chagrin. If you look at the economic profiles of physicians, the time that doctors truly started getting wealthy in this country and making exorbitant salaries was when Medicare got passed.

Q. What was the biggest effect of Medicare on older Americans?

A. There’s no two ways about the fact that it was positive for older Americans. Clearly Medicare worked, and it still works today. I have never polled physicians, but think that a high number of them today would say let’s “Medicarize” all of health and have a single-payment system.

Q. How can people maximize their own care when they see a doctor?

A. Doctors always joke that the best thing any individual in this country can do to protect themselves from the health care system is to have a doctor within the family.

Q. Why?

A. I don’t know how people navigate the system without having a professional in the family. It’s one of those things that is complicated far beyond what it needs to be in terms of the delivery of health care.

Q. How so?

A. The ideal situation for all of us is to have a doctor who knows you, who takes care of you. Then if something happens and you have to be admitted to the hospital, he or she admits you, and is there when you arrive, says hi, coordinates your health care, and hopefully you get better. But we don’t have any of that; it doesn’t exist anymore.

Q. How do you help your own family navigate the system?

A. My mother fell down, she hurt her ankle. Mom is 86, so she went to a doctor with her swollen ankle. They wanted to do X-rays, and a CT scan, and the doctor wanted to see her every week for a while. It was ridiculous! The woman had a bruised ankle. There is nothing you can do about that. Just give it time.

Q. So how can laypeople keep an eye out for unnecessary expenses and tests?

A. I don’t think they can. That’s the pragmatic problem with American health care. Doctors do test upon test to both diagnose and then cover themselves in case there are lawsuits. For me it’s a very tough situation—as a physician I understand why the doctors do what they do. But I also understand the detrimental effects it can have on an individual, not only from a physical standpoint undergoing possibly unnecessary tests, but also from a financial standpoint.

Q. Are there any medical advocates who can do this for patients?

A. You have to have someone who knows the system. I’m sure that some entrepreneurial young man or woman is going to wake up someday and say, “You know, I can usher patients through their medical care.”

Q. Like a wedding planner.

A. Yeah, a health care planner. It’s just a matter of time.

Q. Where is medical research today on the chronic diseases we have not been able to conquer, such as heart disease and cancer?

A. We react to things; we don’t prevent things. American medicine is reactive for the obvious reason that it pays more to take care of a person who has lung cancer.

Q. How?

A. Just think of all the people who profit off of someone having lung cancer. It’s far beyond just the doctors—it’s the insurance companies and the entire medical industry. If you’re telling teenagers, “Don’t smoke,” and they don’t smoke, well, nothing happens. No one’s making any money, and they grow to adulthood, and no one dies from lung cancer, and everybody’s happy—but no one makes any money off of it.

Q. So modern research is creating more treatments than preventive measures?

A. Right. Reacting to problems is obviously not the way that you want to deliver health care, yet it is the only thing that we know how to do. Really, before the 1960s, the only individuals who were making money off of health care were the doctors. Medicine was 3 to 4 percent of our gross national product. Today we’re almost at 20 percent. When President Obama attempts to change the system, so many people are affected by the changes, it’s no longer just the doctors who are crying, “Hey, don’t do that, we aren’t going to get paid.” The book points out how we got to where we are, and it just connects these health care dots into a framework and makes it easier to understand.

Betsy Towner lives in California.