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Commercial Pressures on Professionalism in American Medical Care: From Medicare to the Affordable Care Act

Published online by Cambridge University Press:  01 January 2021

Theodore R. Marmor  and
Robert W. Gordon
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Extract

This essay describes how longstanding conceptions of professionalism in American medical care came under attack in the decades since the enactment of Medicare in 1965 and how the reform strategy and core provisions of the 2010 Affordable Care Act (ACA) illustrate the weakening of those ideas and the institutional practices embodying them.

The opening identifies the dominant role of physicians in American medical care in the two decades after World War II. By the time Medicare was enacted in 1965, associations of American physicians were almost completely in charge of medical education, specialist certification, and the enforcement of professional norms on their members. Who could be a doctor, what education and training would be required, and what collegial oversight was operative was first a professional matter and only secondly implicated the state through malpractice or major corporations via the employment of physicians.

Type
Symposium
Information
Journal of Law, Medicine & Ethics , Volume 42 , Issue 4 , Winter 2014 , pp. 412 - 419
Copyright
Copyright © American Society of Law, Medicine and Ethics 2014

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References

See Durkheim, E., Professional Ethics and Civic Morals, Brookfield, C., trans. (Westport, Conn: Greenwood Press, 1983). Veblen, T., The Higher Learning in America (New Brunswick: Transaction Publishers, 1993); Tawney, R. H., The Acquisitive Society (New York: Harcourt, Brace and Co., 1948). Haskell, T., “Professionalism versus Capitalism,” in Haskell, , ed., The Authority of Experts: Studies in History and Theory (Bloomington: Indiana Univ. Press, 1984): 180–225.Google Scholar
For documentation of the decline of professional authority, see, among many works, S. Brint, In an Age of Experts: The Changing Role of Professionals in Politics and Public Life (Princeton: Princeton Univ. Press, 1994) and Krause, E. A., The Death of the Guilds: Professions, States and the Advance of Capitalism 1930 to the Present (New Haven: Yale Univ. Press, 1996).Google Scholar
See for this documentation and explanation, C. Tuohy, Accidental Logic (New York: Oxford University Press, 2000).Google Scholar
For further discussion of the Canadian experience in comparative terms, see Marmor, T. Freeman, R. Okma, K., eds., Comparative Studies and the Politics of Modern Medical Care (New Haven: Yale University Press, 2009).CrossRefGoogle Scholar
This discussion of the language of professional commentary draws on Marmor, T. R., Fads, Fallacies and Foolishness in Medical Care Management and Policy (Singapore: World Scientific Publishing, 2009). See especially chapter one.Google Scholar
This article in not the appropriate place to discuss at length the long, contentious, and continuing argument about user charges in medical care financing. There is a series of seven papers that two decades ago reviewed the literature on the subject for the Ontario Premier's Council on Health, Well-Being and Social Justice in 1993. Those articles are available from the University of British Columbia's Centre for Health Services and Policy Research. For a summary of them, see this article: Evans, R. Barer, M. L. Stoddart, G. L., >“User Fees for Health Care: Why a Bad Idea Keeps Coming Back,”> Canadian Journal on Aging 14, no. 2 (1995): 360–390. Their perspective is clear. see especially Evans, R. G.et al, “User Fees for Health Care: Why a Bad Idea Keeps Coming Back,” Health Policy Research Unit Discussion Paper #93–9D, 1993. While the work of Evans and his colleagues is well known in other industrial democracies, they are hardly cited at all in the health economics literature published in the United States.CrossRefGoogle ScholarPubMed