The history of the American railroad system and why this matters for healthcare

What does the history of the American railroad system and healthcare have in common?

Growing up, I always found trains and the railways to be fascinating. I remember my Uncle had a model train set in his basement that weaved in and out of detailed mountains and quaint hand painted towns. I was always fascinated how one had to plan carefully where each line of track was laid to maximize the amount of space the train had to move about the landscape.

Because of this interest, whenever I hear something on railroads I tend to pay attention.

Planning and fundraising: Railroad’s beginnings

A story on NPR described in great detail the history of the railroad system in the US, and how this system forever shaped the way our economy works. The author of Railroaded: The Transcontinentals and the Making of Modern America highlighted how politics and business became intertwined leading to some of the problems we are witnessing today in American politics. What does the history of the American railroad system and healthcare have in common?Listening to NPR this morning, I was struck by a story describing the history of the railroad system in the US, and how this system forever shaped the way our economy works. The author of Railroaded: The Transcontinentals and the Making of Modern America was describing how politics and business became intertwined leading to some of the problems we are witnessing today in American politics. However, it was one point regarding the building and financing of the railroad system that I want to highlight.The author was describing how the railroad system was being built somewhere between 30 and 40 years before it was really going to be used regularly. Because of this, there was difficulty getting buy in from across the board to fund such an initiative and taxpayer dollars had to subsidize the investment. Now there are a lot more details to speak of here, but I was blown away thinking that a system was built 30 years before it was “really” needed.Transition point: In the Tour de France, if you are hit by a car, fall, recover and keep riding.   The current healthcare system has evolved over time to become more expensive and inefficient. There have been some excellent pieces written on the history of healthcare - while I will not go into detail on this here, a nice piece in Slate describes some of the humble beginnings of the healthcare system we know today:“What we recognize as modern medicine, Cohn writes, began in the 1920s.  That’s when doctors and hospitals, having only during the previous  decade learned enough about disease that they could be reliably helpful  in treating sick people, began charging more than most individuals could  easily pay. To close this gap, which worsened with the advent of the  Great Depression, the administrator of Baylor Hospital in Dallas created  a system that caught on elsewhere and eventually evolved into Blue  Cross. The Blues were essentially nonprofit health insurers who served  local community organizations like the Elks. In exchange for a tax  break, Blue Cross organizations kept premiums reasonably low.”Bottom line: “Capitalism can’t deliver decent health care.”How much did the pioneers of healthcare plan or even think 30 years ahead?How often did the originators of health insurance think 30 years down the road to consider the impact of their decisions?Was the healthcare “system” created with the future in mind or simply something that had to be done at the time to “fix” what was broken?Maybe I am taking this a bit far, but similar to prevention in healthcare, people often don’t want to address (read pay for) something that is not going to be immediately beneficial.At the time, was the railroad system immediately beneficial? According to the story, no. However, without that railroad system decades later, many things would not have been possible.What can we do to plan 30 years ahead for healthcare? Can we? Is this even possible in the current political system? Maybe we should do ourselves a favor and consider that the current system is broken, and it may be time to plan ahead for something better.

However, it was one point regarding the building and financing of the railroad system that I want to highlight.

The author talked about how the railroad system was being built somewhere between 30 and 40 years before it was really going to be used.

Just think about that for a second; 30 or 40 years before it would be used. Think about the planning that must have had to go into that process.

Because of this time delay, there was difficulty getting buy in from across the board to fund such an initiative; therefore, for the most part, taxpayer dollars had to subsidize the investment. Without going into more details about the economics of this, I want to focus in on the fact that a group of leaders designed a system 30 years before it was “really” needed.

Transition point: Click here for a detailed railroad timeline and history.

The railroad and healthcare?

So what does the history of the railroad have to do with healthcare?

If one looks at the history of healthcare, similarly to the history of the railroad, there are themes. The current healthcare system has evolved over time to become more expensive and inefficient but was it created that way?

There have been some excellent articles written on the history of healthcare – while I will not go into detail on this here, a nice piece in Slate describes some of the humble beginnings of the healthcare system we know today:

“What we recognize as modern medicine, Cohn writes, began in the 1920s. That’s when doctors and hospitals, having only during the previous decade learned enough about disease that they could be reliably helpful in treating sick people, began charging more than most individuals could easily pay. To close this gap, which worsened with the advent of the Great Depression, the administrator of Baylor Hospital in Dallas created a system that caught on elsewhere and eventually evolved into Blue Cross. The Blues were essentially nonprofit health insurers who served local community organizations like the Elks. In exchange for a tax break, Blue Cross organizations kept premiums reasonably low.”

Bottom line: “Capitalism can’t deliver decent health care.”

The author concludes that: “Markets can do many wonderful things, which is why I’m glad to live in a capitalist country. But they’ve made a complete hash of the healthcare system. Doesn’t that reality deserve more than passing respect?”

How much did the pioneers of healthcare plan or even think 30 years ahead? While there is not way for them to predict a meteoric rise in chronic disease and obesity, didn’t they think that healthcare was only going to become more important?

How often did the originators of health insurance think 30 years down the road to consider the impact of their decisions?

Was the healthcare “system” created with the future in mind or simply something that had to be done at the time to “fix” what was broken?

Maybe I am taking this a bit far, but similar to prevention in healthcare, people often don’t want to address (read pay for) something that is not going to be immediately beneficial.

At the time, was the railroad system immediately beneficial? According to the story, no. However, without that railroad system decades later, many things would not have been possible. That railroad system literally changed the United States.

What can we do to plan 30 years ahead for healthcare? Can we? Is this even possible in the current political system?

Maybe we should do ourselves a favor and consider that the current system is broken, and it may be time to plan ahead for something better.

Dr. Miller has his doctorate in clinical psychology and is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. His core task is to integrate mental health across all three of the department’s core mission areas: clinical, education, and research. Opinions expressed here are his own and not those of his employer.

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  • @nursesallie

    Big infrastructure projects usually have that extended timeline. Starr covers the whole American medicine thing. We’ve seen the rise of docs the rise of insurers. Hopefully next the rise of patients. I am sure we will see lots of small good models of innovation. But right now we have to expect a significant cost and timeline to see effects of better primary care and wait out much of current chronic illness
    I think population-based
    interventions are the way to go.

    Starr

    • http://flavors.me/collaborativecare Ben Miller

      Thanks for the comment. I agree with you, and love your notion of the “rise of the patient.” For too long we have been discussing the need for change. Now, we are starting to see the community demand more from healthcare; challenge and disrupt the status quo. This matters greatly. To have a system that is built around the patient, we must first start to know what the patient wants and needs.

      I also agree that having a more population based approach is the way to go.