The Social Transformation of American Medicine

"This is a very long, detailed book, and it’s not all that easy for someone who is not deeply into health policy and healthcare to relate it to today. Its purpose is to describe the broad sweep of the history of healthcare in America, through to about 1980. It was published in 1982 so it’s not even that current. But it’s necessary reading for anybody who fancies themselves as a health policy wonk or expert, or a health historian, or anybody who works in healthcare. I found it fascinating, and I didn’t even know about it until relatively recently. I’ve put it on this list to remind people of its existence, because it should be more widely known and read. The parallels. He traces the development of institutions, many of which remain in positions of power as they did in the past, and have been able to amass more power. There have been some changes over the century, but many things have stayed the same. He tells stories about the politics of reform and prior reform efforts – of which there were a lot, even before 1980. You could lift so many passages from that book and people would say “Oh, you’re talking about 2009” and you’d say “No, that was 1917 or 1937”. It would be great to impress upon people that these issues of healthcare reform that we fight about so passionately today are the same issues people have been fighting about in the US for 100 years. That’s the reason to read this book. We have spent decades on these issues, and perhaps up to half of us are still not convinced that we’ve taken a reasonable step in the latest reform. Just thinking about that is stunning – the number of years we’ve gone with the level of uninsurance we have in this country, and the rate of increase in healthcare costs. They’ve been escalating faster than any other country since about 1980. Unfortunately, Starr’s book ends right when the US healthcare trajectory, in terms of spending, diverges from the rest of industrialised countries. Look at the graphs and it’s in about 1980 that the US starts taking off, and everybody else stays at a lower level. And we’re still diverging. This is partly what my next choice, Paul Starr’s most recent book Remedy and Reaction, is really about. It’s describing what he and others call the US health policy trap. That trap is that we’ve evolved to a point where most people and most voters are insured, either through an employer or Medicare. Therefore, they and the institutions that they benefit are resistant to change. It’s very hard to move the system to something that would be more sensible. Right now, the reason people cling to employer-based care is because it’s what they know. On one level, it works. Yes it’s expensive and inefficient, but it’s what they know, it seems to work for them. That’s why it’s hard to change. No. It’s widely recognised that a more rational system would sever the connection between health insurance and employment. To the extent that the debate is over policy, it’s about how to get there and under what terms. To the extent that the debate is over politics, it’s just too easy to use the spectre of change to frighten people. It creates too many distortions in the labour market. A lot of people will take and hold onto jobs for the health insurance, not because the job makes sense in terms of the work or even in terms of wages. There are many people who don’t retire because of health insurance. There are even studies that show that there is lower creation of small businesses and less entrepreneurship because of health insurance. It’s an unnecessary constraint on the labour market and on job creation, and it just doesn’t need to be that way. No, and it’s not just me. I would defy anybody to come up with it. If you could go to a world where you are unaware of the American system and then design a system, there is no way you would come up with anything like what we have here. It’s just preposterous. It doesn’t make sense on so many levels. The risk pools are chopped up, there are many inefficiencies and strange subsidisations. Nobody would do it that way. One couldn’t even imagine that it would be possible. You can’t make this stuff up."