Development of the City-County (Public) Hospital

Prior to 1966, the United States had a two-tiered system of health care.^1-4 Those patients who could afford the cost of medical care were treated by private physicians in their offices and in private hospitals. For patients who could not afford care, ie, the indigent and retirees over 65 years of age who developed catastrophic illnesses, the city and county (public) hospitals provided the only health care available. All counties assumed responsibility for their indigent patients, and all but the smallest counties had their local hospital. In the larger cities, these hospitals developed teaching programs and affiliations with medical schools that provided a volunteer teaching faculty (Table) (John G. Raffensperger, unpublished data, 1991; John E. Salvaggio, unpublished data, 1989).^5-11 The smaller county hospitals relied on a few full-time generalists, but primarily they depended on volunteer physicians from the community to provide patient care. With the passage of federal