PACEMAKER: Centennial 1998

Innovative solutions preserve Iowa's commitment to indigent care

Providing medical and surgical care to the poor was the traditional role of hospitals in the 18th and 19th centuries, and it was one of the arguments for establishing University Hospital, which opened in 1898. But another equally important reason for the College of Medicine to operate a hospital was to train physicians, so in addition to the care patients received, they also served as subjects for the clinical instruction of medical students.

With charity care being dispensed by individual counties, however, there was no statewide system to address the medical needs of poor Iowans and little incentive for counties to send patients to Iowa City rather than to local doctors.

One influential critic, in fact, believed the number of patients admitted to University Hospital was too low to provide adequate clinical training to students. Abraham Flexner, a national health care reformer who surveyed all 155 U.S. and Canadian medical schools in 1909 (and found all but a handful deficient), questioned whether a small community like Iowa City could ever provide enough hospital patients to meet the College of Medicine's educational needs.

University and state officials were determined to address Flexner's concerns. They studied a Michigan law that provided state funding for the medical and surgical care of indigent children at the University of Michigan Hospital in Ann Arbor. Seeing an ideal mechanism both to increase University Hospital admissions and to provide care for poor Iowans, they fashioned similar legislation.

The Perkins Act, as it was called after its chief sponsor, Senator Eli Perkins of Delhi, gained legislative approval and went into effect in 1915. It stipulated that any child under 16 whose parents were unable to pay for necessary medical or surgical care--as certified by a district court judge-could receive care at University Hospital at state expense. In 1919 the law was expanded to include indigent adults as well as children.

The laws had a dramatic effect on University Hospital. By 1930 total admissions reached 12,800-triple the pre-1915 level-with two-thirds of them being state indigent patients. The increased number of patients solved the problem of insufficient clinical volume once and for all, but it strained the physical capacity of University Hospital and prompted the move to an all new medical campus on the west side of the Iowa River.

The program also strained state finances. In 1925 the legislature moved to limit its open-ended commitment to indigent care by capping its appropriation for the program, an amount that actually decreased with the onset of the Great Depression in 1929.

While legislators set a limit on the indigent care appropriation, however, there was no limit on the number of patients the counties could send to University Hospitals. A crisis developed as Iowans certified for care, but unable to receive it because of the spending cap, were put on a waiting list that grew into the thousands.

Two innovative solutions to this crisis are still in effect today. First, University Hospitals instituted a county quota system which calculated the number of patients who could be served with the available funding, then apportioned this number fairly among Iowa counties based on population. Second, the hospitals set up a statewide ambulance service to transport patients to and from Iowa City more efficiently.

The growth of hospitalization insurance as an employment benefit after the 1950s, and the passage of federal Medicare and Medicaid legislation in 1965, reduced but didn't eliminate the need for the state indigent care program. Today approximately 5,000 Iowans are admitted to University of Iowa Hospitals and Clinics thanks to a program with turn-of-the-century roots.