The Social Transformation of American Medicine: The rise of a sovereign profession and the making of a vast industry

529 Pages·1984·40.87 MB·English

by  Paul Starr

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PAUL STARR
The Social Transformation
of American Medicine
BLANK PAGE
THE
SOCIAL
rRANSFORMATION
OF AMERICAN
MEDICINE
PAUL STARR
BASIC
B
BOOKS
A Member of The Perseus Books Group
To the Memory
of My Father
Library of Congress Cataloging in Publication Data
Starr, Paul, 1949-
The social transformation of American medicine.
Includes bibliographical references and index.
1. Medical care—United States—History. 2. Social
medicine—United States—History. 3. Physicians—
United States—History. I. Title. [DNLM: 1. History
of medicine, Modern—United States. WZ 70 AAi S7S]
BA395.A3S77 1982 3os'.96i'o973 81-68412
ISBN-13 978-0-465-07935-3
ISBN-10 0-465-07935-0
Copyright © 1982 by Paul Starr
Printed in the United States of America
Designed by Vincent Torre
DHAD 60 59 58 57 56 55 54 53 52 51 50
CONTENTS
Preface ix
Acknowledgments xi
BOOK ONE
A SOVEREIGN PROFESSION
The Rise of Medical Authority and
the Shaping of the Medical System
INTRODUCTION
The Social Origins of Profesional Sovereignty 3
THE ROOTS OF AUTHORITY
Dependence and Legitimacy
Cultural Authority and Occupational Control
STEPS IN A TRANSFORMATION
The Growth of Medical Authority
From Authority to Economic Power
Strategic Position and the Defense of Autonomy
CHAPTER ONE
Medicine in a Democratic Culture, 1760-1850 30
DOMESTIC MEDICINE
PROFESSIONAL MEDICINE
From England to America
Professional Education on an Open Market
The Frustration of Professionalism
THE MEDICAL COUNTERCULTURE
Popular Medicine
The Thomsonians and the Frustration of Anti-Professionalism
THE ECLIPSE OF LEGITIMATE COMPLEXITY
vi Contents
CHAPTER TWO
The Expansion of the Market 60
THE EMERGING MARKET BEFORE THE CIVIL WAR
THE CHANGING ECOLOGY OF MEDICAL PRACTICE
The Local Transportation Revolution
Work, Time, and the Segregation of Disorder
THE MARKET AND PROFESSIONAL AUTONOMY
CHAPTER THREE
The Consolidation of Profesional Authority, 1850-1930 79
PHYSICIANS AND SOCIAL STRUCTURE IN MID-NINETEENTH-
CENTURY AMERICA
Class
Status
Powerlessness
MEDICINE'S CIVIL WAR AND RECONSTRUCTION
The Origins of Medical Sectarianism
Conflict and Convergence
Licensing and Organization
MEDICAL EDUCATION AND THE RESTORATION OF OCCUPA-
TIONAL CONTROL
Reform from Above
Consolidating the System
The Aftermath of Reform
THE RETREAT OF PRIVATE JUDGMENT
Authority over Medication
Ambiguity and Competence
The Renewal of Legitimate Complexity
CHAPTER FOUR
The Reconstitution of the Hospital 145
THE INNER TRANSFORMATION
Hospitals Before and After 1870
The Making of the Modern Hospital
THE TRIUMPH OF THE PROFESSIONAL COMMUNITY
THE PATTERN OF THE HOSPITAL SYSTEM
Class, Politics, and Ethnicity
The Peculiar Bureaucracy
CHAPTER FIVE
The Boundaries of Public Health 180
PUBLIC HEALTH, PRIVATE PRACTICE
The Dispensary and the Limits of Charity
Health Departments and the Limits of Government
FROM REFORM TO THE CHECKUP
The Modernization of Dirt and the New Public Health
The Prevention of Health Centers
Contents vi
CHAPTER SIX
Escape from the Corporation, 190-1930 198
PROFESSIONAL RESISTANCE TO CORPORATE CONTROL
Company Doctors and Medical Companies
Consumers' Clubs
The Origins and Limits of Private Group Practice
CAPITALISM AND THE DOCTORS
Why No Corporate Enterprise in Medical Care?
Professionalism and the Division of Labor
The Economic Structure of American Medicine
BOOK TWO
THE STRUGGLE FOR MEDICAL CARE
Doctors, the State, and the Coming
of the Corporation
CHA P T E R ONE
The Mirage of Reform 235
A COMPARATIVE PERSPECTIVE
The Origins of Social Insurance
Why America Lagged
GRAND ILLUSIONS, 1915-1920
The Democratization of Efficiency
Labor and Capital Versus Reform
Defeat Comes to the Progressives
EVOLUTION IN DEFEAT, 1920-1932
THE NEW DEAL AND HEALTH INSURANCE, 1932-1943
The Making of Social Security
The Depression, Welfare Medicine, and the Doctors
A Second Wind
SYMBOLIC POLITICS, 1943-1950
Socialized Medicine and the Cold War
Three Times Denied
CHAPTER TWO
The Triumph of Acomodation 290
THE BIRTH OF THE BLUES, 1929-1945
The Emergence of Blue Cross
Holding the Line
The Physicians' Shield
THE RISE OF PRIVATE SOCIAL SECURITY, 1945-1959
Enter the Unions
A Struggle for Control
The Growth of Prepaid Group Practice
The Commercial Edge
THE ACCOMMODATION OF INSURANCE
vi Contents
CHAPTER THREE
The Liberal Years 35
AID AND AUTONOMY, 1945-1960
Public Investment in Science
The Tilt Toward the Hospital
THE STRUCTURAL IMPACT OF POSTWAR POLICY
The New Structure of Opportunity
The New Structure of Power
REDISTRIBUTION WITHOUT REORGANIZATION, 1961-1969
The Liberal Opportunity
Redistributive Reform and Its Impact
The Politics of Accommodation
CHAPTER FOUR
End of a Mandate 379
LOSING LEGITIMACY, 1970-1974
Discovery of a Crisis
The Contradictions of Accommodation
The Generalization of Rights
The Conservative Assimilation of Reform
HEALTH POLICY IN A BLOCKED SOCIETY, 1975-1980
An Obstructed Path
The Generalization of Doubt
The Liberal Impasse
THE REPRIVATIZATION OF THE PUBLIC HOUSEHOLD
CHAPTER FIVE
The Coming of the Corporation 420
ZERO-SUM MEDICAL PRACTICE
The Doctor "Surplus" and Competition
Collision Course
THE GROWTH OF CORPORATE MEDICINE
Elements of the Corporate Transformation
The Consolidation of the Hospital System
The Decomposition of Voluntarism
The Trajectory of Organization
DOCTORS, CORPORATIONS, AND THE STATE
Notes 450
Index 496
PREFACE
I HAVE DIVIDED this history into two books to emphasize two long
movements in the development of American medicine: first, the rise of
professional sovereignty; and second, the transformation of medicine
into an industry and the growing, though still unsettled, role of corpora-
tions and the state. Within this framework I explore a variety of specific
questions, such as:
why Americans, who were wary of medical authority in the early and
mid-nineteenth century, became devoted to it in the twentieth;
how American doctors, who were bitterly divided and financially
insecure in the nineteenth century, became a united and prosperous
profession in the twentieth;
why hospitals, medical schools, clinics, and other organizations as-
sumed distinctive institutional forms in the United States;
why hospitals became the central institutions in medical care;
why public health did not;
why there is no national health insurance in the United States;
why Blue Cross and commercial indemnity insurance, rather than
other types of health plans, dominated the private insurance market;
why the federal government in recent years shifted from policies that
encouraged growth without changes in the organization of medical
care to policies that encouraged reorganization to control growth;
why physicians long escaped from the control of the modern corpora-
tion, but are now witnessing and indeed taking part in the creation of
corporate health care systems.
This last question became more salient while this book was in prog-
ress. When I began work in 1974, it was widely thought that medical
schools, planners, and administrators were emerging as the chief coun-
terweight to private physicians. Government seemed to be assuming a