Observing the ongoing privatization in Britain’s National Health Service, it is hard not to look across the pond to where it feels as though privatization’s fullest expression in healthcare: the United States. It is through this lens that I approached Guian A. McKee’s Hospital City, Health Care Nation: Race, Capital, and the Costs of American Health Care, a comprehensive, ambitious history of how hospitals became central institutions in American political economy as well as in urban life.

McKee tells this story through a case study of the world-renowned Johns Hopkins Hospital (JHH) and its surrounding East Baltimore neighborhoods, threading that local “hospital city” into the making of a broader “health care nation.” The book follows JHH from the postwar Hill–Burton Act building boom through Medicare and Medicaid; from hospital labor conflicts and cost control in the 1970s through the rise of managed care and for-profit hospital chains; and finally, the real estate redevelopment of the late twentieth and early twenty-first centuries. Moving back and forth between Washington and Baltimore, the narrative reveals the embeddedness of federal policy debates in local decisions on capital investment, urban renewal, and community engagement.

One of Hospital City’s central claims is that, by the late twentieth century, hospitals—nominally community-based, egalitarian institutions—had come to resemble profit-seeking enterprises while not distributing profits in a formal sense. Federal programs originally intended as social welfare, particularly Medicare and Medicaid, financed a growing share of services that hospitals had once provided free of charge. Beyond operational costs, these programs reimbursed capital expenditures and even guaranteed a set profit margin. Together with tax-exempt bonds and mortgage loans, these public and private funds sustained an era of debt-financed healthcare expansion that put institutions such as JHH in “a long-term position where they could gain market share, shape prices, and further influence the politics of health care reform” (p. 164).

The other major thread of the book is race politics in urban spaces. McKee reconstructs Hopkins’s role in the Broadway urban renewal project, which displaced hundreds of families from a Black-majority neighborhood to make space for residential and commercial properties that served JHH’s staff. In the late 1960s and 1970s, Black workers and community leaders attacked the fact that white workers had more supervisory and high-paying roles and educational opportunities than Black workers within JHH (p. 132). Even initiatives aimed at easing this tension, such as the East Baltimore Medical Plan, masked the broader need for community development and poverty alleviation by focusing solely on residents’ medical needs.

For business historians, two features of Hospital City seem particularly valuable. First, McKee effectively reframes public, not-for-profit, or humanitarian organizations, such as hospitals, as businesses or quasi-commercial entities. Medicare and Medicaid, he shows, did not simply subsidize care for older and disadvantaged populations; they fueled hospital growth by financially rewarding previously voluntary services and by enabling facility and footprint expansions. As hospitals such as JHH turned away from philanthropy toward financial instruments, they emerged as “economic and political players capable of shaping both the health care system and the communities in which they operated” (p. 68). This framework will resonate with historians of other business-like organizations, from research universities to care homes and nongovernmental organizations (NGOs). Equally, it invites comparative work with pharmaceutical and clinical trial industries that operate at the porous boundary between shareholder value and public good.

Second, McKee treats quasi-commercial organizations such as hospitals as active agents in reshaping local communities. He questions the view of hospitals merely as neutral, knowledge-seeking institutions pursuing medical excellence; rather, they are active participants in mediating social inequalities and city infrastructure. JHH appears not only as a global medical center but as a landlord pursuing gentrification projects, an employer whose internal labor markets were racially segmented, and a de facto arm of the welfare state that “medicalized its engagement with the neighborhood’s social problems” when other forms of social provision fell away (p. 105). The framing of “‘social function’ as an employer and institutional anchor in an increasingly deindustrialized city” (p. 157) offers a fruitful conceptual bridge between urban history and the literature on anchor institutions and local capitalism. Business historians interested in racial capitalism, municipal finance, or social enterprises will find rich material here, even though McKee’s protagonists are hospital executives and public officials rather than the business stakeholders.

Overall, Hospital City is a major contribution to the history of American healthcare and to the study of how large service organizations operate as businesses within their local communities. For readers in business history, it offers both a detailed case study of a seminal medical institution and useful arguments about capital, medical governance, and urban space that travel well beyond the ward.