Starr divides the history of medicine into two books in order to emphasize two separate movements in the development of American medicine. The first movement was the rise of professional sovereignty and the second was the transformation of medicine into an industry, with corporations taking a large role.
Book One: A Sovereign Profession
In the first book, Starr begins with a look at the shift from domestic medicine in early America when the family want the locus of care of the sick to the shift towards the professionalization of medicine in the late 1700s. Not all were accepting, however, as lay healers in the early 1800s saw the medical profession as nothing but privilege and took a hostile stance to it. But then medical schools began to emerge and proliferate during the mid-1800s and medicine was quickly becoming a profession with licensures, codes of conduct, and professional fees. The rise of hospitals and the introduction of telephones and better modes of transportation made physicians accessible and acceptable.
In this book, Starr also discusses the consolidation of professional authority and the changing social structure of physicians in the nineteenth century. For instance, before the 1900s, the role of doctor did not have a clear class position, as there was a lot of inequality. Doctors did not earn much and a physician’s status depended largely on their family’s status. In 1864, however, the first meeting of the American Medical Association was held in which they raised and standardized requirements for medical degrees as well as enacted a code of ethics, giving the medical profession a higher social status. Reform of medical education reform began around 1870 and continued through the 1800s.
Starr also examines the transformation of American hospitals throughout history and how they have become central institutions in medical care. This happened in a series of three phases. First was the formation of voluntary hospitals that were operated by charitable lay boards and public hospitals that were operated by municipalities, counties, and the federal government. Then, beginning in the 1850s, a variety of more “particularistic” hospitals formed that were primarily religious or ethnic institutions that specialized in certain diseases or categories of patients. Third was the advent and spread of profit making hospitals, which are operated by physicians and corporations. As the hospital system has evolved and changed, so has the role of the nurse, physician, surgeon, staff, and patient, which Starr also examines.
In the final chapters of book one, Starr examines dispensaries and their evolvement over time, the three phases of public health and the rise of new specialty clinics, and the resistance to corporatization of medicine by doctors. He concludes with a discussion of the five major structural changes in the distribution of power that played a major role in the social transformation of American medicine:
1. The emergence of an informal control system in medical practice resulting from the growth of specialization and hospitals.
2. Stronger collective organization and authority/the control of labor markets in medical care.
3. The profession secured a special dispensation from the burdens of hierarchy of the capitalist enterprise. No “commercialism” in medicine was tolerated and much of the capital investment required for medical practice was socialized.
4. The elimination of countervailing power in medical care.
5. The establishment of specific spheres of professional authority.
Book Two: The Struggle for Medical Care
The second half of The Social Transformation of American Medicine focuses on the transformation of medicine into an industry and the growing role of corporations and the state in the medical system. Starr begins with a discussion on how social insurance came about, how it evolved into a political issue, and why America lagged behind other countries with regards to health insurance. He then examines how the New Deal and the Depression affected and shaped insurance at the time.
The birth of Blue Cross in 1929 and Blue Shield several years later really 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.
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, which Starr discusses. He also examines the key events that formed and shaped the insurance industry, including World War II, politics, and social and political movements (such as the women’s rights movement).
Starr’s discussion of the evolution and transformation of the American medical and insurance system ends in the late 1970s. A lot has changed since then, but for a very thorough and well-written look at how medicine has changed throughout history in the United States up until 1980, The Social Transformation of American Medicine is the book to read. This book is the winner of the 1984 Pulitzer Prize for General Non-Fiction, which in my opinion is well deserved.
Starr, P. (1982). The Social Transformation of American Medicine. New York, NY: Basic Books.