- U.S. Health Policy and Health Care Delivery: Doctors, Reformers, and Entrepreneurs by Carl F. Ameringer
In U.S. Health Policy and Health Care Delivery: Doctors, Reformers, and Entrepreneurs, Carl F. Ameringer argues that healthcare in the United States reflects the triad of doctors, entrepreneurs, and reformers between 1870 and 2015. Ameringer's focus is on health care delivery (physicians and hospitals) rather than universal coverage. He argues that understanding only the failure in the expansion of insurance leaves the story of U.S. health care incomplete. Understanding the "health care industry," and how its "composition and configuration" determines what is provided and how much health care will cost (p. 1) is important, he argues. If, in health systems elsewhere, doctors and entrepreneurs are more effectively controlled by government (p. 13), in the United States, stakeholders are in charge. While Ameringer might be overstating consensus and rational policy in other countries, it is true that universal health care systems more coherently corral providers.
The work of Rosemary Stevens1 and Daniel Fox2 naturally provides a backdrop for Ameringer's approach to professional and hospital stakeholders, but he focuses more on the political economy of professional power. Ameringer succinctly captures the ascendancy of the American Medical Association (AMA), including its successive efforts to strangle competition and stave off challenges to physicians' autonomy in the healthcare sector. Among many terrific vignettes of AMA influence, is the AMA-initiated rebellion against managed care in the 1990s. While there is a perception that public opposition was whipped up, it could conceivably have been inevitable. Ameringer pinpoints 1992 as the start of a coordinated public relations campaign by the AMA designed to turn public support against managed care. The protest was a manufactured meme, derived from the 1940s playbook on defeating socialized medicine.
A second strength of the book is its recognition of the importance of the courts. If Congress was the arena for ideological arguments on coverage, state court decisions incrementally and quietly dictated the contours of a delivery system that particularly rewarded physicians. On occasion, Group Health legal cases addressed anticompetitive behavior; in the 1970s and 1980s, Goldfarb and Maricopa (p. 94) changed the ability of the medical profession to enjoy unique protections from antitrust laws.
Courts are sometimes portrayed as filling the holes in national healthcare policy; however, courts became tools that fashioned professional control and were strategically used by organizations like the AMA. One key case was Dent (an 1889 Supreme Court decision), which originated in West Virginia—the first state to license physicians. West Virginia had established a board for licensing physicians, [End Page 312] but the board would only grant licenses to those who had graduated from a "reputable medical college" (p. 19). Of course, what was "reputable" was an AMA-derived designation. Frank Dent, a practitioner who was trained in eclectic medicine, fought a misdemeanor charge for practicing medicine without a license. The Supreme Court decision ruled against him, and affirmed state medical society control of licensing, but worse, never defined what the "practice of medicine" meant. Any activity involved in treating or healing patients thus became under the scope of the profession.
Third, the book is timely. Chapter 5 explains well the marketization of healthcare and, building on the triad theme, Ameringer shows the challenge government faces (in issues like hospital mergers) in making the determination of what a well-functioning market looks like. While the book would have benefitted from a thematically organized conclusion chapter that weighed the influence of the triad setup, Ameringer's final chapter brings us to 2015 and is a well-organized overview of significant policy and sector changes.
To conclude, there are many insightful links made in this book between the interaction of law and politics that forged our non-health care system. The book nicely incorporates stories of specific individuals and organizations in local or state contexts whose experiments or actions took on larger significance. This is a compact, highly readable story of the jostling of...