A system at war with itself

From pages 227 and 232 of Paul Starr’s The Social Transformation of American Medicine and pertaining to U.S. health care circa 1920:

The structural features Arrow[*] discusses have a history. He writes that when the market fails, “society” will make adjustments. […] One has to ask: For whom did the market fail, and how did “society” make these adjustments? The competitive market was failing no one more than the medical profession, and it was the profession that organized to change it. […]

By the 1920s, the medical profession had successfully resolved the most difficult problems confronting it as late as 1900. It had […] won stronger licensing laws; turned hospitals, drug manufacturers, and public health from threats to its position into bulwarks of support; and checked the entry into health services of corporations and mutual societies. It has succeeded in controlling the development of technology, organizational forms, and the division of labor. In short, it had helped shape the medical system so that its structure supported professional sovereignty instead of undermining it.

Over the next few decades, the advent of antibiotics and other advances gave physicians increased mastery of disease and confirmed confidence in their judgment and skill. The chief threat to the sovereignty of the profession was the result of this success. So valuable did medical care appear that to withhold it seemed deeply unjust. Yet as the felt need for medical care rose, so did its cost, beyond what many families could afford. Some agency to spread the cost was unavoidable. It would have to be a third party, and yet this was exactly what physicians feared. The struggle of the profession to maintain its autonomy then became a campaign of resistance not only to programs of reform but also to the very expectations and hopes that the progress of medicine was constantly arousing. To continue to escape the corporation and the state meant preserving a system that was at war with itself.

* Arrow, Kenneth J. “Uncertainty and the Welfare Economics of Medical Care.” American Economic Review 53 (December 1963), pp. 941–73.

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