The Social Transformation of American Medicine: A Comparative View from Germany

In The Social Transformation of American Medicine (1982), Paul Starr argues that physicians in the United States exercise authority over patients, fellow workers in health care, and even the public at large. This authority spills over its clinical boundaries into arenas of political action for which medical knowledge is only partly relevant. According to Starr, the medical profession has been able to turn its authority into social privilege, economic power, and political influence. Hardly anywhere have doctors been as successful as American physicians in resisting national insurance and maintaining a predominantly private and voluntary financing system. Physicians in the United States have not only escaped from corporate and bureaucratic control in their practices, they also have been able to channel the development of hospitals, health insurance, and other medical institutions into forms that did not intrude upon their autonomy (5-6).

The enactment of compulsory social health insurance legislation in other Western capitalist countries suggests there was no fundamental reason that the United States could not also have adopted social health insurance. However, Starr argues, the medical profession was one of the main opponents of compulsory social health insurance. No powerful coordinating authority was permitted to emerge, because it would have threatened professional autonomy and physician control of the market. Even though universal health insurance would have boosted the income of many physicians, private doctors resisted the idea for fear of compromising their independence (26).

As a consequence, U.S. government took no action to subsidize voluntary health insurance funds or to make sickness insurance compulsory. This was the case even though the three main opponents (the medical profession, labor, and business) had conflicting and ambiguous interests and despite the fact that interest groups in Europe had been shown to often benefit from governmental health insurance programs. Ideology, historical experience, and the overall political context played a key role in shaping how groups in the United States identified and expressed their interests differently from corresponding groups in Europe (255).

The defeat of consecutive attempts to bring about national health insurance meant that health insurance in the United States would be predominantly private and thereby available to select population groups. Starr writes about how the insurance system developed under the control of hospitals and doctors, how the medical profession was able to turn third-party insurers from a potential threat into a source of greatly increased income, and how the insurance system accommodated the profession's interests and on those terms the profession accommodated health insurance. Even in setting up Medicare, Congress and the administration of President Lyndon B. Johnson were acutely concerned with gaining the cooperation of doctors and hospitals. Only rising concerns of government, private insurers, and employers about increasing health care costs and the pressures of the managed care revolution compromised the profession's ability to turn authority into social privilege, economic power, and political influence (445).

Although Starr refers to the European experience with the introduction of social health insurance in order to explain why "America lagged," The Social Transformation of American Medicine does not take up a comprehensive comparative perspective. We argue that—if it did—differences between the autonomy of the medical profession in Germany and the United States would in fact be much smaller than they appear to be in the book. Professional organizations of physicians in Germany—the country with the longest tradition of compulsory social health insurance—even today are very protective of their professional autonomy, their income, and their market shares. We argue further that, in the long run, the corporatist structure in countries with compulsory social health insurance has protected the interests of the medical profession at least as effectively, perhaps even more so, as in the United States.

The case of Germany offers an excellent opportunity to study the pathway from the apparent loss of autonomy after the introduction of compulsory social health insurance toward the strong economic and political position of today's medical profession as a corporatist actor.¹

In this essay, we first review Starr's depiction of...