Nancy Tomes has written an important book that anyone interested in health care or consumer studies should read. While bits and pieces of medicine's consumer-oriented features have shown up in previous scholarly works, Tomes brings them together and adds fresh material to break new ground in the history of medicine and political economy.
Many observers associate the patient-as-consumer ethos with the 1970s women's health movement or the recent blossoming of the Internet. But Tomes looks to the early twentieth century for the origins of today's commercial-jingle-humming patient who, armed with a WebMD report, might just as well visit the physician's office as the corner pharmacy's “MinuteClinic.” For both medical and pharmaceutical markets, Tomes documents three periods of “consumerist agitation”: the interwar period, when the idea of patients as consumers first emerged; the 1940s through the 1960s, which she describes as “free enterprise medicine”; and the post-1960s consumer's revolution.
During the first period, patients sought the bounties of modern medicine, which brought groundbreaking innovations in pharmaceuticals, vaccines, and medical procedures. Increased demand drove rising prices, and the quantity and quality of health services often depended on a patient's wealth. To attract the affluent, who could be charged more according to the physician's sliding-fee scale, doctors set up their offices as “showrooms” to display their wares in a “dignified” manner. Reformers, acting on behalf of consumers, attempted to reorganize this market for lower costs by promoting prepaid doctor groups. But the American Medical Association (AMA) denounced such efforts as “Bolshevism.”
While physicians managed to protect their individualist tradition and ward off reforms to effect efficiency, retail chains like Walgreens spread to challenge locally founded drugstores. The 1906 Food and Drugs Act offered consumers protection from some of the worst crimes of the nostrum industry. Yet, consumers continued to navigate murky waters. The difference between over-the-counter and prescription drugs was often unclear. And doctors, under the influence of advertising, frequently favored expensive proprietary medicines and purposely obscured their treatment decisions by writing prescriptions in Latin. “Consumerist agitation” primarily consisted of groups educating patients on how to buy intelligently by viewing advertisements and labels with a critical eye.
After World War II, during the second consumer period, observers increasingly questioned the social reputation of the doctoring profession. Large, un-itemized bills and a nationwide scandal involving unnecessary surgery drove demands for medical societies to establish patient “grievance committees.” As prescription drug prices rose and observers questioned the efficacy and necessity of many new-line medicines, some consumers began to doubt the physician's ability to act as the patient's advocate.
Accumulating misgivings brought about the third era of consumer activism. Welfare, women, and African American groups protested medical paternalism and service inequality by establishing their own clinics and sponsoring health care shopping guides. Despite these politically radical connections, consumerism gained “respectability” during the 1970s medical cost crisis, when patients were urged to search for “qualified” physicians and obtain second opinions before undergoing costly procedures such as surgery. Politicians, regulators, and judges increasingly sided with consumer activists who sought information about the safety of their care.
During the 1980s and 1990s, consumers responded to a rapidly commercializing health care sector. Under “managerial medicine,” insurance companies focused more on cost cutting than on care quality. For-profit companies, such as Humana and the Hospital Corporation of America (HCA), gained impressive market share. In the pharmaceutical industry, legal restrictions were gradually eroded so that drug companies could launch massive direct-to-consumer ad campaigns. Today, patient-consumers complain about the difficulty of accessing services that are fragmented across numerous medical specialties and about how little time their physicians have to spend with them. Consumer advocates also worry that pharmaceutical companies exercise too much influence over physician decision making.
Tomes knows how to tell a story—she peppers her analysis of legislative debates and regulatory changes with numerous people and anecdotes. She also breathes analytical heft and narrative verve into familiar historical episodes; see, for example, her discussion of the Committee for the Costs of Medical Care and the Humphrey-Durham amendments.
I offer two quibbles with this otherwise excellent book. While Tomes is correct that well-informed, activist consumers have offered only a “weak corrective” to the medical system's problems, she tends to miss how much patients were straightjacketed by a very specific system. Refreshingly, she does see that health care took a particular path away from prepaid doctor groups toward insurance and fee-for-service billing. However, she neglects to tease out the full implications, not only of that economic model but also of the AMA's power. The association's ability to force such arrangements on consumers foreclosed a wide variety of patient options and foisted them into a high-cost, inequality-laden system. The book does not fully explore how AMA rules against commercialism hindered consumer information, since it was almost impossible to compare physician pricing, nor how employer-provision hid the high costs of insurance from most consumers. Moreover, the power that organized doctors initially wielded over medical licensing allowed them to shut out African American and women physicians, a situation that only encouraged the medical patriarchy's abuses, which ranged from unequal service quality to unnecessary hysterectomies, performed in the name of profits, racism, and eugenics (a topic that I'm surprised Tomes misses).
My only other cavil—which, in all fairness, I can only offer because of my own research—is that she overlooks how important insurance companies were to some of the trends she identifies, such as the move away from home visits, which insurers would not reimburse, or the increasing necessity of medical offices, where administrators could help doctors manage insurance communications and paperwork. Most important, the AMA's insistence that insurance companies pay doctors on a fee-for-service basis fueled unnecessary hospitalizations, surgeries, and procedures. However, these equivocations involve the production side of medicine, which is not the focus of Tomes's book and with which she does a commendable job considering her primary emphasis.
Tomes admirably expands the boundaries of health care scholarship. She does so by painting a rich historical portrait of consumers experiencing and interacting with the nation's medical system.
