Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (Book Review)
Much of U.S. medical care, particularly the everyday business of preventing and treating routine medical illness is inferior in quality, wastefully dispensed, and inequitably financed. . . . Whether poor or not, most Americans are badly served by the obsolete, over-strained medical system that has grown up around them helter-skelter . . . the time has come for radical change. (Fortune Magazine, 1970; quoted on p. 381).
The more things change, the more they stay the same!
I have been wanting to read this book for years. My doctoral research was about literature and medicine (specifically: anatomy) in the 16th century and that caused me to read very broadly in the history of medicine. This book, though, starting in the mid-18th century, was outside my research horizon so I never read it. I wish I had, because the introduction which situates Starr's arguments around authority, controls, the nature of professions and the structure of institutions is very much in keeping with what I was thinking about in the Tudor era in England. Anyway . . . this will be mildly spoiler-y but I outline some bits to whet your appetite.
The text is organized into two "books," the first one covering the mid-18th century up to the 1920s. It's very interesting, and explains how physicians managed to get control of healthcare and became the essential adjudicator of structure, process, and money. The first book is pretty straight history: serious stuff. You'll find quite a bit about the emergence of medical schools, and competition between doctors and para-medical disciplines (e.g., homeopathy). Then the second book takes us from the Great Depression to the 1980s. Because this second book talks about, essentially, the dismantling of the sovereignty of the profession of doctoring, it's more polemical, and also has some moments of humor to alleviate the disturbing saga of healthcare shooting itself in the foot over and over again. Finally, there's a fantastic Epilogue that reflects on all of that and takes the story up to 2016.
The book is chock full of little sections that provide origin stories for things we take for granted: For instance, Blue Cross (p. 295), Blue Shield (p. 306), the rise of healthcare tied to employment (pp. 311ff), Kaiser and Group Health (p. 321), the NIH (p. 340: did you know that it emerged from the Marine Hospital Service of the 1880s?), etc. I'm not a doctor, so much of the story here was pretty surprising to me: I did not realize that hospitals make their services available to doctors, and see doctors as funnels for business: Thus there is endless competition between doctors and hospitals, each trying to get the buck. There are also endless quotations of statistical facts that provide points of comparison to the present: For instance, "The average private physician in 1930 saw about 50 patients per week; by 1950, he saw more than one hundred" (p. 359). Huh. As another example of something I've tended to just take for granted is the difference between Medicare Part A and Medicare Part B. I've known for a long time that Part A was about hospital insurance and Part B was outpatient insurance including medically necessary procedures and preventive services . . . But did you know that in 1965, A originated from the Democrats while B came from the Republicans? (p. 369). To find out why, you'll have to read the book.
Anyway, the super-broad summary of the second book is that we almost had universal healthcare under Nixon in 1974, but that probably didn't happen because of Watergate (p. 405). After the 1970s, there was a tremendous amount of consolidation in healthcare; much of this narrative follows Starr's sad witticism that "In health reform, a little known law of nature seems to require that every move toward regulation be followed by an opposite move toward litigation" (p. 407). Political deadlock was the dominant paradigm through the 80s, though there are hints of what was to come. For instance, Starr notes in passing (regarding the late 70s) that "To discourage insurers from only enrolling the affluent and the healthy, they would be paid according to the actuarial risk that their subscribers represented (more for the aged, the poor, and so on)" (p. 413) -- you can see modern risk adjustment coming. The 80s were about cost containment. The 90s were about Clinton's failure to re-org healthcare.
The Epilogue goes over the dominance of PPO programs, the advent of the ACA and its doubtful economic merits (though, to be sure, many more people are insured), and the emerging interest in quality and safety. The book ends by reflecting on the rhetoric of consumerism in healthcare.
I would strongly recommend this to anyone interested in American history, particularly if you're interested in institutions, professions, and politics; and certainly anyone currently working in healthcare who wonders how we got here.
Originally reviewed on Goodreads on 7 September 2020.
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