I am a physician engaged in the US healthcare system for the past 50 years. I read Starr's book first in 1985. For me, engaging this book was like "Saul on the road to Tarsus" . The film fell away from my eyes and for the first time, I began to "see" the American healthcare system. The complete title of the book is: "The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a VAST INDUSTRY". The title is completely apt and accurate. US medicine has experienced transformation and will continue to undergo change. American physicians as a profession boot-strapped themselves into a dominant force that effectively protected the boundaries of the profession from any outside encroachment up until around the 1990s. US doctors did not possess the status of a "sovereign state within a state" but they came close. For assorted reasons that Starr illuminates, doctors came to a point in the late 20th century where they no longer could keep "big business" at bay or curb inexorable relentless price inflation in medical goods & services. They fought a rearguard action for several decades against the "marauding barbarians at the gate" until such time "Big Business" breached the Rhine River and invaded the US doctors' turf.
The second aspect of Starr's book title is described as the "Making of a Vast Industry". US Healthcare system (US HS) understood as a "Vast Industry" is a "vast" understatement. US Healthcare is a mega- gigantic, mind-numbingly immense "Industrial- Complex" unlike anything seen on the planet earth. The US HS was HUGE in the 1980s and 1990s;. Consequently, measures were set in motion to break the upward-directed cost curve. The rate of rise was moderated but THE RISE continued, and like an out-of-control Godzilla, scavenges the countryside - consuming vastly large sums of money lying loose in its pathway. For example, 2020 US health care expenditures approached $3.8 TRILLION.
Very few Americans could truly grasp just how much money $3.8 trillion is. To put that in perspective: If US Healthcare were a "sovereign country" it would rate 5th in the world - based on the size of its GDP- exceeded only by China, Japan, and about tied with Germany. Walmart the largest corporation in America based on yearly revenue takes in ~ $546 B; Amazon takes in $347 B and 3rd place goes to Apple @ $ 274 B. Of the top 13 companies in the US Fortune 500 ranking, 5 companies belong to the "Healthcare Industry". Together these 5 companies haul in $1.6 TRILLION. The top 3 companies: Walmart, Amazon, and Apple together collect $1.17 Trillion. It was recently reported that US Big Pharma (J&J, Pfizer, Merck, Lily, etc) based on revenue generated from the sale of the TOP 20 Drugs absorbs >$100 Billion-- MORE than every other country on the planet- COMBINED!
AND, it's actually WORSE than it seems. Scholars have consistently observed over the past 30 years that the administrative overhead within "the system", i.e. transactional costs incurred in measuring, tracking, overseeing, controlling "the system" - consumes ~ 20% - 25% of the total costs. OR about $700 billion/ year. This overhead is considered "deadweight" "dross" "waste".
$700 billion in deadweight is appreciably more money than Walmart makes in an entire year. $700 billion is about the same amount of money the USA elects to spend yearly on "defense" - DoD procurements; AND this sector of spending ie "Arms & Weapons" is more than every country on the planet earth spends on "defense" - COMBINED!
Most countries in the OECD spend ~ 7% -13% on administrative costs.
Starr's book provides the seriously inquisitive student of US Healthcare Policy an explanation of how these staggering numbers came to be and why they continue to be relatively so immense.
Finally, Starr does not call into question healthcare service quality. It has been and remains very good. The primary problem is: it is so damn expensive!
Starr alludes to some of the reasons for this. The "Social Transformation of American Medicine", though, is a sociological analysis of the environment and of varied factors - a deep context - out of which a "Vast Industry" emerged and continues to thrive.
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