To the benefit of all of us, Paul Starr has published an updated version of Social Transformation of American Medicine. Nearly everyone in health policy, health politics, or health law who has taken undergraduate or graduate study in the subject—to say nothing of the study of professions, the history of science, the sociology and history of medicine, and the political economy of health—will be familiar with this magisterial 1982 volume. Reading the updated edition gives students and scholars alike a chance to reengage with Starr's centuries-spanning narrative of the rise of the American medical profession to combined social, economic, and political dominance over the sphere of American health care. To the classic material, Starr appends a new epilogue surveying the last 35 years in light of what came before it.
Revisiting the text in the twenty-first century provides an opportunity to examine Starr's history in light of subsequent academic developments, as well as the intervening years. Starr's second chapter, “Medicine in a Democratic Culture, 1760–1850,” reads as ever more perceptive in light of four decades of historical, sociological, and political science inquiry that connect the American Revolution more tightly to democratizing patterns in antebellum America. These years saw the undermining of ecclesiastical authority (Hatch 1989), of patriarchal household dominance (Cott 1977; Salmon 1986), of slaveholding magisterium (Sinha 2016), and of landed rentier economies (Huston 2000; McCurdy 2006). It saw the democratization of American political life (Wilentz 2005) and even the democratization of capital through free banking (Lamoreaux 1997; Moss and Brennan 2001). Starr's description of democratic culture during the “long Revolution” provides a necessary basis for the later liberation of professional expertise. The rise in meritocratic professional authority required first, in some sense, the rupture of earlier barriers that hindered scientific advance. The power accumulated by the medical profession in the late nineteenth century replaced another form of dominance, weakened by cultural democratization.
Rereading Starr's chapters on “The Consolidation of Authority, 1850–1930” and “The Escape from the Corporation, 1900–1930” reminds us of other work written since that sketches the role of professional and state forces in weakening corporate power. The hitching of doctors' authority to that of the hospital required the capitalization of medicine's physical plant, as well as a freer vision of municipal government's role in health policy, as detailed in such works as Judith Walzer Leavitt's The Healthiest City (1996) on progressive Milwaukee, or Charles Rosenberg's insightful study “From Almshouse to Hospital” (1982) on the transformation of Philadelphia Hospital, published the same year as Starr's first edition. The decline of quackery-based alternatives to organized medicine came in part through the assertion of Progressive and New Deal Era state power, as shown by such narratives as Stephen Skowronek's Building a New American State (1982), Theda Skocpol's Protecting Soldiers and Mothers (1992), and my own Forging of Bureaucratic Autonomy (Carpenter 2001) and Reputation and Power (Carpenter 2010). Starr's prescient assignment of a central role to the Mayo Clinic in the transformation of organizational models in twentieth-century medicine develops a narrative that deserves a book of its own.
Starr's book 2 on physicians, the state, and the emergence of the medical corporation has probably received the most attention from scholars. Important reinterpretations to the story have been rendered by the sociologist Andrew Abbott (1988) and the political scientist Jacob Hacker. Hacker in particular develops Starr's earlier point that incremental innovations in health insurance actually undermined the long-term effort for comprehensive health insurance provision in America. In his celebrated article “The Historical Logic of National Health Insurance” (1998) that compares the American experience to that of Britain and Canada, and in his book The Divided Welfare State (2002) contrasting the trajectories of social insurance and health insurance, Hacker showed how each seemingly momentary pause in national health insurance reform efforts allowed private insurers to populate an exclusive marketplace (after the failure of the Truman effort, for example), or politically fortified the exclusive nature of health provision (after Medicare). In many ways, however, these reinterpretations merely reinforce the outlines of the Starr narrative.
Starr's epilogue to this new edition of Social Transformation of American Medicine is a deft, wide-ranging summary of complicated and intertwining developments in the political economy of American health care. Readers may expect, and they indeed receive, summaries of the battle over the Clinton health care plan and Obamacare. Yet they also see some of the most thoughtful summaries yet written of changes in health insurance policies and organizations, the emergence of preferred-provider organizations and point-of-service plans, the rise of capitation-based payment schemes, and the introduction of tax-favored high-deductible health plans (456–61). Starr links these patterns to aggregate risk shifting in a decentralized but no less incessant fashion (466–68), what Hacker has demonstrated to be a society-wide phenomenon in his volume The Great Risk Shift (2008).
To this reader, the most important contribution of the epilogue consists in an apt summary of the provider concentration that has buffeted American health care in the last three decades. Mergers and acquisitions in the hospital sphere exploded ninefold from 1990 to 1996, and the pace reaccelerated after 2010. Starr relates the deeply precedent-setting merger of Massachusetts General and Brigham to form Partners HealthCare in 1994, followed in 2000 by a collusive agreement between Partners and Blue Cross that hiked health care prices statewide. Partners HealthCare became so powerful that it was able to bully Tufts Health Plan to accede to its terms. Hospitals have integrated not only horizontally by merging with other hospitals but also vertically by buying up practice groups such as radiologists, surgical units, skilled nursing facilities, and home health providers. An abundance of health policy research now demonstrates increases in cost and price in these regional monopolies. These developments were made possible by the weakening of antitrust and merger regulations at the state and federal level, which were themselves facilitated by changes in academic and legal doctrine, not only the Chicago school of law and economics (as Starr points out more generally) but also more specifically the doctrine of contestable markets in which a plain monopoly can be considered less threatening because there always lurks the possibility, if not the actuality, of an entrant.
Starr concludes the epilogue with a poetic cautionary note, reminding us that the formal reliance on price systems has led to an informal surrender to market power. It is a deft echo of the idea that the dream of reason forgot to account for power.
Starr's volume stands sufficiently on its own, but I would like to see scholars attend to two other recent developments that Starr left aside. While Starr notes the dramatic growth of technology-intensive medicine, there is room in academia for a treatment of the way that medical technology and medical practice have combined to create new centers of wealth and political power. The presence of pharmaceutical treatment was a known variable in the first edition of Social Transformation. To this has been added a vast market for medical devices (at $180 billion in industrial revenues per year and rapidly growing)—artificial knees and hips, coronary stents, pacemakers and the like. In recent years the growth in medical device aggregate spending has generally been well above that for pharmaceuticals.
Medical devices have reempowered surgeons in ways that are beginning to remap American medicine. And with the aging of the US population, accompanied by changes in obesity, these patterns are likely to grow only stronger. The marginal benefit for physicians to prescribe most drugs is pretty minimal, unless the treatment is administered in a hospital setting, but the marginal benefit of “prescribing” a device is far larger. The administration of treatment by device almost always involves surgery of some sort, and cardiologists and orthopedic practitioners have been making millions of dollars from these treatments. The medical device industry is highly concentrated industrially in the United States, and it counts surgical specialty associations as among its most important political allies. Compared to the pharmaceutical industry, it has been far less stringently regulated by the Food and Drug Administration.
A second development also concerns wealth and power, and its outlines at this moment are forming before our eyes. For generations the American medical profession made its money from a broad swath of the American population. This was due in part to the distribution of wealth and income in the United States and in part to government insurance programs. As income and especially wealth are ever more concentrated in the hands of a smaller portion of society since 1970 (see Piketty 2014), a larger share of the demand for medical services comes from the wealthy. Where employees are covered by generous employer-provided health insurance, or where they can pay for a larger share of costs out of pocket, they and their problems begin to attract more attention from physicians and hospitals. Those physicians and medical practices that can forgo Medicare and Medicaid do so because they have lucrative alternatives. Starr reflects on some of this, but there is another treatment waiting. The rise of boutique medical clinics, concierge medicine, and specialized hospitals that cater to wealthy patients (including those who live overseas) is beginning to restructure opportunities for citizens and medical professionals alike. There may be an association between the rise of these services and the growth of average patient wait times in large cities. Not only do wealthy patients foot the bill for services like these, but some also donate immense sums to hospitals, to university medical centers, and to physician practice groups. The upward redistribution of wealth is remaking medical queues and the very physical plant of American health care. In the rise of medical technology and its reempowerment of select specialties, and in the restructuring of American medicine upon boutique and systematic service to the wealthy, new forms of power need to be taken into account. Starr's magisterial treatment points us in the right direction.