In the Social Transformation of American Medicine, Starr takes a long historical view of the medical profession and the role of doctors in it, paying attention to issues like hospitals, public health policies and among others. He traces the roots of our contemporary health care system to a changing culture and a shifting economy and makes its growth and development clear and comprehensible. Starr talks about the major health care reforms, the problems, and developments of the last four decades: the rise of third-party health insurance, such as Blue Cross and Blue Shield, and employee health benefits, the political struggle to create Medicare and Medicaid, the effort to establish regulatory control over expansion of the hospital system, flourishing technology, and increasing costs of healthcare.
I agree when Starr mentions that the doctors always enjoyed unprecedented social status and they used to operate in a free-market atmosphere. Physicians made sure that nothing came between them and their patients. The AMA’s public strategy was to defend the kind of practice in which the doctor and only doctor charged fees for medical services. This model was held to assure both the quality of care and patients’ freedom of choice. Of course, such an arrangement also assured each doctor control of his own practice and his economic fortunes. Whenever government, business corporations, labor unions, community agencies, or any other third party threatened the fee-for-service arrangement by attempting to hire their own physicians, organized medicine reacted strongly.
Hospitals became the central institutions in American medical care during the early 20th century. The proliferation of nonprofit community hospitals, which focused on surgery and acute care and were dependent on patients' payments rather than Government support, gave doctors crucial leverage. Only doctors could order the admissions that filled the beds and use the hospital as a highly profitable second office to generate fees. Physicians used their authority to limit free dispensaries and prevent the development of health centers. I agree that doctors, as mentioned by Starr, prohibited public health programs from offering curative medical care and effecting private fee-for-service practice.
The birth of Blue Cross and Blue Shield paved the way for health insurance in America because it reorganized medical care on a prepaid, comprehensive basis. This was the first time that “group hospitalization” was introduced and provided a practical solution for those who could not afford typical private insurance of the time. Doctors boycotted businesses and insurance companies that hired doctors to provide direct medical services and forced them to retreat into insuring against the costs - on the physicians' own terms. They resisted prepaid group practice until such groups triumphed in the courts through application of antitrust laws. And they argued successfully that it was unethical for anyone except doctors to make a profit from personal medical services.
Shortly after, health insurance emerged as a benefit received via employment, which reduced the likelihood that only the sick would buy insurance and it reduced the large administrative costs of individually sold policies. Commercial insurance expanded and the character of the industry changed.
I agree with Starr’s prediction that corporate influence will expand exponentially into the field of medicine. The major change corporation of medicine has brought about is the "break down in voluntarism." In the past, voluntary motivations drove medicine. In the 1970's and 1980's, this changed completely as all aspects of medicine began to take on for-profit goals and is continue today.
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