注释

上部 主权专业

引言 专业主权的社会起源

1.M.I.Finley,The Ancient Economy (London:Chatto&Windus,1973),57;N.D.Jewson,"Medical Knowledge and the Patronage System in 18th Century England,"Sociology 8 (September 1974),369-385;Theodore Zeldin,France 1848-1945,vol.1,Ambition,Love and Politics (Oxford:The Clarendon Press,1973),23-42.

2.David K.Shipler,"Life for Soviet Women All Work,Little Status," New York Times,August 9,1976.

3."American versus European Medical Science,"Medical Record 4 (May 15,1869),133.

4.见 Steven Lukes，“Power and Authority，” in A History of Sociological Analysis，ed.Robert Nisbet and Tom Bottomore （New York：Basic Books，1978），642。

5.Hannah Arendt,"What is Authority?" in Between Past and Future (New York:Viking,1961),93.

6.那些遵循马克斯·韦伯传统的权威分析家们有时倾向于强调合法性而不提依赖。韦伯本人指出，下属服从权威有很多原因，包括无助和对权威所拥有的权力的恐惧。但他把合法性作为分析的组织原则，并在他的权威类型的理论模型中特别排除了其他因素，如无助感。见Max Weber，Economy and Society，ed.Guenther Roth and Claus Wittich （New York：Bedminster Press，1968），I：214。我和韦伯的不同在于，我将依赖加入模型，并强调依赖和合法性之间的张力。Peter Blau提出在依赖条件的基础上发展另一种权威类型学的想法。参见他的文章，“Critical Re-marks on Weber’s Theory of Authority，”American Political Science Review 57 （June 1963），305-316。

7.Lukes，“Power and Authority，”640.Lukes在此总结了Carl Friedrich的想法。

8.Ibid.,640.

9.在这方面，可参见Marcia Millman，The Unkindest Cut （New York：William Morrow，1977），Chap.9。

10.通过对依赖性和合法性予以同样程度的强调，我旨在唤起人们对权威关系中的矛盾心理的关注，这一点在更理想化的解释中，尤其是在对传统型或超凡魅力型权威的解释中往往被忽略。关于权威的情感层面，参见Richard Sennett，Author-ity （New York：Knopf，1980）。

11.许多关于医学专业和医患关系的研究工作只集中在治疗功能上。对医生的行政管理作用的分析可参见Deborah Stone，“Physicians as Gatekeepers：Illness Certifi-cation as a Rationing Device，”Public Policy 27 （Spring 1979），227-254。

12.Weber，Economy and Society，I：53；另见编者们对翻译Herrschaft之困难的讨论（ibid.，61-62），以及韦伯对权威统治和经济权力统治的区分（按照他们的译法）（ibid.，III：941）。

13.Lukes将我称作“文化”和“社会权威”的东西描述为“凌驾于信念的权威”和“凌驾于行为的权威”。然而，他又把凌驾于信念的权威定义为将权威概念化的三种方式之一，另外两种方式分别是惯例的权威和强加的权威。这种分类似乎很不成功。Lukes倾向于将权威的不同方面当作另一种的模型。

14.转引自Arendt，Between Past and Future，123。

15.这种三分法—集体的、认知的、道德的—不属于任何一位作者，但我认为这涵盖了有时甚至冗长的属性清单中的主要内容。对于试图定义一个专业之本质的尝试，参见Ernest Greenwood，“Attributes of a Profession，” Social Work 2 （July 1957），44-55；Morris L.Cogan，“Toward a Definition of Profession，” Harvard Educational Review 23 （Winter 1953），33-50；Talcott Parsons，“The Professions and Social Structure，” in Essays in Sociological Theory，rev.ed.（Glencoe，Ill：Free Press，1954），34-39。关于一种有影响力的发展模型，见Harold L.Wilensky，“The Pro-fessionalization of Everyone？” American Journal of Sociology 70 （September 1964），137-158。批判性的评论可参见Terence J.Johnson，Professions and Power （London：Macmillan，1972）。

16.Johnson，Professions and Power；另 见 Eliot Freidson，Profession of Medicine （New York：Dodd，Mead，1970）。

17.例如，参见Richard H.Shryock，Medicine in America：Historical Essays （Balti-more：Johns Hopkins University Press，1966），以及William G.Rothstein，American Physicians in the Nineteenth Century：From Sects to Science （Baltimore：Johns Hopkins Press，1972）。在Rosemary Stevens，American Medicine and the Public Interest （New Haven，Conn.：Yale University Press，1971）中，科学造成了专门化，而这又成为该专业内政治冲突的焦点。按照她的叙述，专业未能应对专门化的挑战—即对更加协调的组织和筹资的需求—构成了其未能满足公众利益的原因。

18.对于为获得权威的斗争及其与变动的社会组织的关系，有一个很好的叙述，参 见 Thomas L.Haskell，The Emergence of Professional Social Science （Urbana，Ill.：University of Illinois Press，1977）。

19.Eliot Freidson,Professional Dominance:The Social Structure of Medical Care (New York:Atherton,1970),117.

20.帕森斯的经典论述可参见The Social System （Glencoe，Ill.：Free Press，1951），Chap.10。

21.见Robert K.Merton and Elinor Barber，“Sociological Ambivalence，” in Socio-logical Theory，Values and Sociocultural Change，ed.Edward A.Tiryakian （New York：Free Press，1963），91-120。

22.见Freidson，Profession of Medicine，esp.Chap.7。

23.Magali Sarfatti Larson,The Rise of Professionalism (Berkeley:University of Cal-ifornia Press,1977),14.

24.如果公司在监管外部订约人时遇到严重的信息问题，并且怀疑这些订约人有不同的目的，或者是重组劳动过程的障碍，他们就会有强烈的动机将其直接纳入自己的组织。见Oliver E.Williamson，Markets and Hierarchies：Analysis and An-titrust Implications （New York：Free Press，1975），以及Stephen Marglin，“What Do Bosses Do？”Review of Radical Political Economics 6 （1974），60-112。

25.关于医生在道德行为立法中的作用，见 James C.Mohr，Abortion in Amer-ica：The Origins and Evolution of National Policy，1800-1900 （New York：Oxford University Press，1978）；James Reed，From Private Vice to Public Virtue：The Birth Control Movement and American Society Since 1930 （New York：Basic Books，1978）；Linda Gordon，Women’s Body，Women’s Right：Birth Control in America （New York：Penguin，1977）；and David Pivar，Purity Crusade：Sexual Morality and Social Control （Westport，Conn：Greenwood，1973）。

第一章 民主文化中的医学（1750—1850）

1.Oliver Wendell Holmes,"The Position and Prospects of the Medical Student,"in Currents and Counter Currents in Medical Science (Boston:Ticknor and Fields,1861),316.

2.财富方面日益不平等的证据，见James A.Henretta，The Evolution of American Society，1700-1815 （Lexington，Mass：Heath，1973），103-106，以及Edward Pessen，Riches，Class and Power Before the Civil War （Lexington，Mass：Heath，1973），31-45。Pessen试图通过证明美国存在严重而稳固的财富集中来推翻托克维尔的“平等主义论点”，但他的证据并没有回应托克维尔关于美国文化的更大更复杂的论点。

3.Alexis de Tocqueville，Democracy in America，tr.Henry Reeve （New York：Schocken，1961），II：211.关于对年龄的尊重程度下降的一系列显著证据，见David Hackett Fischer，Growing Old in America （New York：Oxford University Press，1977），77-112。关于杰克逊时期的一般政治历史，见Arthur M.Schlesinger，Jr.，The Age of Jackson （Boston：Little，Brown，1945）。

4.William Buchan，Domestic Medicine，or the Family Physician...，2nd ed.（Phila-delphia，1771），171.关于他的作品在美国的多个版本，见Francesco Guerra，Amer-ican Medical Bibliography，1639-1783 （New York：Lathrop C.Harper，1962），191。Francis Packard在1931年写道，他认为巴肯作品的使用频率比任何其他同类书籍都要高，而且将来也不会被超越。该书出版后立即获得成功，在巴肯生前销售了八万册，并被翻译成所有主要的欧洲语言（Dictionary of National Biography，III：180-181）。关于这本书的背景的详细叙述，表明William Smellie可能是共同作者，见 C.J.Lawrence，“William Buchan：Medicine Laid Open，” Medical History 19 （January 1975），20-35。John Blake对这一传统做了出色的描述，见“From Buchan to Fishbein：The Literature of Domestic Medicine，” in Medicine Without Doctors：Home Health Care in American History，ed.Guenter B.Risse，Ronald L.Numbers，and Judith Walzer Leavitt （New York：Science History Publications，1977），11-30。关于巴肯之前的医疗参考书，见 John Tennant，Every Man His Own Doctor，or the Poor Planter’s Physician （Williamsburg，1734），该书曾三次再版。巴肯之后受其影响的著 作，见 Alexander Thomson，The Family Physician：or，Domestic Medical Friend （New York，1802）；James Ewell，The Planter’s and Mariner’s Medical Companion （Baltimore，1813）；以及Blake，“From Buchan to Fishbein，”15-18。

5.Buchan,Domestic Medicine,x,vii.

6.Bernard Semmel,The Methodist Revolution (New York:Basic Books,1973).

7.John Wesley,Primitive Physic:Or an Easy and Natural Method of Curing Most Diseases (1791;reprint ed.,London:The Epworth Press,1960),6-27.

8.John C.Gunn，Domestic Medicine...（New York：Saxton，Barker and Co.，1860），141.冈恩的作品最初于1830年在诺克斯维尔出版，出了许多个版本，到第九版时，销量已超过十万册。见M.E.Pickard and R.C.Buley，The Midwest Pioneer，His Ills，Cures，and Doctors （Crawfordsville，Ind.：Banta，1945）。

9.Wesley,Primitive Physic,26;Buchan,Domestic Medicine,vii-ix.

10.Buchan,Domestic Medicine,58;Lester King,The Medical World of the Eight-eenth Century (Chicago:University of Chicago Press,1958),318-320.

11.Buchan，Domestic Medicine，328-329；另见Gunn，Domestic Medicine，383-384，他说癫痫一般在月圆之夜发作。

12.Keith Thomas,Religion and the Decline of Magic (New York:Scribner,1971).

13.Ibid.,85.

14.Charles E.Rosenberg,The Cholera Years (Chicago:University of Chicago Press,1962),esp.Chaps.2 and 7.

15.W.J.Reader,Professional Men:The Rise of the Professional Classes in Nine-teenth-Century England (New York:Basic Books,1966),16-21,31-43,48-54;S.W.F.Holloway,"Medical Education in England,1830-1858:A Sociological Analysis,"History 49 (1964),299-324.

16.N.D.Jewson，“Medical Knowledge and the Patronage System in 18th Century England，”Sociology 8 （September 1974），369-385；关于贵族庇护与专业化，见Ter-ence J.Johnson，Professions and Power （London：Macmillan，1972）。

17.Richard H.Shryock,Medicine and Society in America:1660-1860 (New York:New York University Press,1960),9-10.

18.Wyndham B.Blanton,Medicine in Virginia in the Eighteenth Century (Rich-mond,Va.:Garrett&Massie,1931),36,20,24,49.

19.J.M.Toner，Contributions to the Annals of Medical Progress in the United States，Before and During the War of Independence （Washington，1874），106.Samuel Haber讨论了“第一波专业化浪潮”，见“The Professions and Higher Education in America：A Historical View，”in Higher Education and the Labor Market，ed.Margaret Gordon （New York：McGraw-Hill，1974）。

20.David Cowan,Medicine and Health in New Jersey:A History (New York:Van Nostrand,1964),6-7.

21.John Morgan,Discourse on the Institution of Medical Schools in America (1765;reprint ed.,Baltimore:John Hopkins Press,1937),xvii;Whitfield Bell,John Morgan,Continental Doctor (Philadelphia:University of Pennsylvania Press,1965).

22.Charles Caldwell，The Autobiography of Charles Caldwell （Philadelphia：Lippin-cott，Grambo，1855），121-122；关于贵族与中产阶级的风尚，见Erving Goffman，The Presentation of Self in Everyday Life （Garden City，N.Y.：Doubleday，1959），33-34。

23.Benjamin Rush,"Observations on the Duties of a Physician,and the Methods of Improving Medicine;Accommodated to the Present State of Society and Manners in the United States," Medical Inquiries and Observations,2nd ed.(Philadelphia:J.Conrad,1805),390-391.

24.Richard H.Shryock,"Benjamin Rush from the Perspective of the Twentieth Century," Medicine in America:Historical Essays (Baltimore:Johns Hopkins Press,1966),237.

25.我对早期医学院的讨论依赖William F.Norwood，Medical Education in the United States Before the Civil War （Philadelphia：University of Pennsylvania Press，1944）。

26.William Rothstein,American Physicians of the Nineteenth Century (Baltimore:Johns Hopkins Press,1972),73.

27.Joseph Kett,The Formation of the American Medical Profession:The Role of Institutions,1780-1860 (New Haven,Conn.:Yale University Press,1968),14-30;Malcolm Sydney Beinfeld,"The Early New England Doctor:An Adaptation to a Pro-vincial Environment,"Yale Journal of Biology and Medicine 15 (December 1942),278.

28.John Duffy,A History of Public Health in New York City,1625-1866 (New York:Russell Sage Foundation,1968),65-66.

29.Rothstein，American Physicians，75-79.这里以及接下来的几段中，我借鉴了Rothstein的论点。

30.Henry B.Shafer,The American Medical Profession,1789 to 1850 (New York:Columbia University Press),221-222.

31.Reginald H.Fitz,"The Rise and Fall of the Licensed Physician in Massachusetts,1781-186o,"Transactions of the Association of American Physicians 9 (1894),1-18.

32.Daniel Drake,Practical Essays on Medical Education and the Medical Profession (1832;reprint ed.,Baltimore:Johns Hopkins Press,1952),91-93.

33.Karl Mannheim，Essays on the Sociology of Knowledge （London：Routledge and Kegan Paul，1952），200；关于早已被遗忘的那些论著中的美国民间医疗信仰的一些例子，见Bruno Gebhard，“The Interrelationship of Scientific and Folk Medicine in the United States of America since 1850，”American Folk Medicine，ed.Wayland D.Hand （Berkeley：University of California Press，1976），87-98。

34.James Still,Early Recollections and Life of Dr.James Still (1877;reprint ed.,New Brunswick,N.J.:Rutgers University Press,1973),77.

35.Pickard and Buley,The Midwest Pioneer,36.

36.Virgil J.Vogel,American Indian Medicine (Norman,Okla.:University of Okla-homa Press,1970),52-54;Otho T.Beall,Jr.and Richard H.Shryock,Cotton Mather:First Significant Figure in American Medicine (Baltimore:Johns Hopkins Press,1954),28,46;Wesley,Primitive Physic,24.

37.Robert J.T.Joy,"The Natural Bonesetters with Special Reference to the Sweet Family of Rhode Island," Bulletin of the History of Medicine 28 (September-October 1954),416-441.

38.Kett,Formation of the American Medical Profession,108.

39.Catherine M.Scholten,"'On the Importance of the Obstetrick Art':Changing Customs of Childbirth in America,1760 to 1825,"William and Mary Quarterly (Sum-mer 1977),427-445.

40.Gerda Lerner,"The Lady and the Mill Girl:Changes in the Status of Women in the Age of Jackson,"in The Majority Finds Its Past:Placing Women in History (New York:Oxford University Press,1979),15-30.

41.Mary R.Walsh，“Doctors Wanted：No Women Need Apply”（New Haven，Conn.：Yale University Press，1978），xiv，3-6，14-16.另见John B.Blake，“Women and Med-icine in Ante-Bellum America，” Bulletin of the History of Medicine 39 （March-April 965），99-123。

42.Richard H.Shryock,"Sylvester Graham and the Popular Health Movement,1830-1870,"in Medicine in America:Historical Essays,111-125.

43.Alex Berman,"The Impact of the Nineteenth-Century Botanico-Medical Move-ment in American Pharmacy and Medicine" (Ph.D.diss.,University of Wisconsin,1954).

44.Samuel Thomson,Narrative of the Life and Medical Discoveries of Samuel Thomson...to which is added An Introduction to his New Guide to Health,2nd.ed.(Boston,1825),43-44.

45.Ibid.,199-200.

46.Thomsonian Recorder 1 (December 15,1832),123.

47.Thomson,Narrative of the Life,41-42.

48.Thomsonian Recorder 1 (June 1,1833),376.

49.Thomson,Narrative of the Life,158;Ronald L.Numbers,"Do-It-Yourself the Sectarian Way,"in Risse,Numbers,and Leavitt,eds.,Medicine Without Doctors,50.

50.Thomsonian Recorder 4 (January 2,1836),106-107;(March 12,1836),187.

51.Ibid.,188.

52.Kett，Formation of the American Medical Profession，130.折衷派也有一个激进的传统。创始人伍斯特·比奇（Wooster Beach）编辑了一份杂志，他在其中谴责了“国王之术、神父之术、律师之术和医生之术”。

53.一些有限的量化证据，见Edward C.Atwater，“The Medical Profession in a New Society，Rochester，New York （1811-60），”Bulletin of the History of Medicine 47 （May-June 1973），221-235；尤其是在上层阶级中支持率下降的问题，见Rosen-berg，The Cholera Years，154-164。

54.Richard H.Shryock,The Development of Modern Medicine (New York:Knopf,1947);Michel Foucault,The Birth of the Clinic (New York:Pantheon,1973);Erwin Ackerknecht,Medicine at the Paris Hospital,1794-1848 (Baltimore:Johns Hopkins Press,1967);Owsei Temkin,"The Role of Surgery in the Rise of Modern Medical Thought,"Bulletin of the History of Medicine 25 (May-June 1951),248-259.

55.Shryock,The Development of Modern Medicine,249.

56.对这些发展的论述，见George Rosen，The Specialization of Medicine，with Particular Reference to Ophthalmology （New York：Froben Press，1944），and Stanley J.Reiser，Medicine and the Reign of Technology （Cambridge：Cambridge University Press，1978）。

57.Ackerknecht,Medicine at the Paris Hospital,Chap.13.

58.Jacob Bigelow,Modern Inquiries:Classical,Professional and Miscellaneous (Boston:Little,Brown,1867),144,230-311;Shryock,Medicine and Society in Ameri-ca,131-132;Charles E.Rosenberg,"The Therapeutic Revolution:Medicine,Meaning and Social Change in Nineteenth-Century America," in The Therapeutic Revolution:Essays in the Social History of American Medicine,ed.Morris J.Vogel and Charles E.Rosenberg (Philadelphia:University of Pennsylvania Press,1979),3-25;John Harley Warner,"The Nature-Trusting Heresy:American Physicians and the Concept of the Healing Power of Nature in the 1850's and 1860's,"Perspectives in American History 11 (1977-78),291-324.

59.Karl Mannheim,"The Democratization of Culture," in Essays on the Sociology of Culture (London:Routledge and Kegan Paul,1956),184-185.

60.1833年12月27日；转引自Thomsonian Recorder 3 （January 17，1835），127。

61.Perry Miller,The Life of the Mind in America (New York:Harcourt Brace&World,1965),102.

62.Henry Steele Commager,The Era of Reform,1830-1860 (New York:Van Nos-trand,1960),71.

63.Lee Benson，The Concept of Jacksonian Democracy （Princeton，N.J.：Princeton University Press，1961）.Benson写道，反共济会运动代表了“‘下层阶级’成员对乡村和城市‘贵族的激烈攻击’”。这种对秘密社团的攻击在医学上也有对应的表现。一个名为卡帕·拉姆达（Kappa Lamda）的不轻易吸收新会员的全国性兄弟会成立于1820年，被指控垄断了医学院和医院的高层职位。1838年，《纽约辉格报》（The New York Whig）发表了一篇揭露性文章，称其为“秘密的、黑暗的、难以捉摸的”。该俱乐部逐渐衰落，最终于1862年关闭。（Kett，Formation of the American Medical Profession，112）

64.关于商业阶层和中产阶级对法律的敌意，见Morton J.Horwitz，The Transfor-mation of American Law，1780-1860 （Cambridge：Harvard University Press，1977），140-159，以及Maxwell Bloomfield，American Lawyers in a Changing Society，1776-1876 （Cambridge：Harvard University Press，1976），44；Matthew A.Crenson，The Federal Machine：Beginnings of Bureaucracy in Jacksonian America （Baltimore：Johns Hopkins Press，1975）。

65.Schlesinger,Age of Jackson,134;James Willard Hurst,The Growth of American Law:The Law Makers (Boston:Little,Brown,1950),280.

66.转引自Harris L.Coulter，Divided Legacy：A History of the Schism in Medical吀ought （Washington，D.C.：McGrath Publishing，1973），Ⅲ：98。

67.见Rothstein，American Physicians一书的附录（332-343）。

68.转引自Coulter，Divided Legacy，95-96；另见Kett，Formation of the American Medical Profession，21-22。

第二章 市场的扩张

1.Karl Polanyi,The Great Transformation (Boston:Beacon Press,1957).

2.Judah v.M'Namee,3 Blackf.269 (Ind.,1833).

3.Wyndham B.Blanton,Medicine in Virginia in the Seventeenth Century (Rich-mond,Va.:Garrett&Massie,1930),250-259;Wilhelm Moll,"Medical Fee Bills,"Virginia Medical Monthly 93 (November 1966),657-664.

4.Pynchon v.Brewster,Quincy 224 (Mass.1776);Glover v.Le Testue,Quincy 225 (Mass.1770).

5.Ruth E.Peters,"Statutory Regulation of Lawyers'Fees in Massachusetts,New York,Pennsylvania,South Carolina,Tennessee,and Virginia from the mid-Seven-teenth Century to the mid-Nineteenth Century." (Unpublished paper,Harvard Law School,May 1975.)

6.New England Journal of Medicine and Surgery 14 （1825），50-51；转引自George Rosen，Fees and Fee Bills：Some Economic Aspects of Medical Practice in 19th-Century America （Baltimore：Johns Hopkins Press，1946），6。

7."Fees and Fee Bills,"Medical and Surgical Reporter 7 (December 7,1861),231-232.

8.Pray v.Stinson,21 Me.(8 Shep) 402;Peck v.Hutchinson,88 Iowa 320,55 N.W.511.

9.Barnes Riznik，“Medicine in New England，1790-1840.” （Unpublished manu-script，Old Sturbridge Village，1963），78-81.在确定债务时，Riznik调查了马萨诸塞州伍斯特县34名“典型”医生的遗嘱记录；26人在去世时有未清偿的债务，一半以上的人欠下了2500美元至10000美元的债务。

10.Riznik，Medicine in New England，1790-1890 （Sturbridge，Mass.：Old Stur-bridge Village，1965），24.这本小册子是作者1963年原稿的缩减版。

11.Richard H.Shryock,Medical Licensing in America,1650-1965 (Baltimore:Johns Hopkins Press,1967),31-32.

12.估算行医的必要投资很困难，因为许多开支是不确定的。许多医生从未上过医学院，或者即使上了医学院，也只上了一个学期，甚至一个学期的一部分；学徒期长短不一。因此，我给出的是费用范围，而不是单一的平均值。费用要素如下：

①三年学徒或诊室学习的费用。

②医学院两个学期（约26周）的学费和生活费。

③马和马车的费用。

④书籍、药品和设备的费用。

⑤投资于学徒期和医学教育的时间机会成本。

⑥投入资金的机会成本，假定正常的收益率为10%。

我的粗略估计如下：①每年50—100美元，乘以3；②150—300美元，取决于学校是在农村还是在城市；③200—300美元；④25—100美元；⑤150美元；⑥35—125美元。低估计值假设以最低的费用做三年学徒，没有正式的医学教育，书本和药品的支出很少（总计560美元）。高估计值按照费用较多的三年学徒期，接受过城市医学教育，图书馆和药品的开支较大来计算（总计1275美元）。显然，如果把住房费用和行医初期收入微薄的阶段养家糊口的需要计算在内，费用会更高。

学徒期和医学院费用的数据直接来自William F.Norwood，Medical Education in the United States Before the Civil War （Philadelphia：University of Pennsylvania Press，1944），393-395。对时间机会成本的估计假定一个无一技之长的20岁男性每年能够获得的收入，相比他作为学徒或待在医学院可能获得的收入，超出部分最多为50美元。

13.见Clarence H.Danhof，“Farm-making Costs and the‘Safety Valve’：1850-1860，”Journal of Political Economy 49 （June 1941），317-359。

14.U.S.Bureau of the Census,Historical Statistics of the United States,Colonial Times to 1970 (Washington,D.C.:Department of Commerce,1975),76 (1850 only);William Barlow and David O.Powell,"To Find a Stand:New England Physicians on the Western and Southern Frontier,1790-1840," Bulletin of the History of Medicine 54 (Fall 1980),386.

15.Riznik,Medicine in New England (1965),15.

16.Barlow and Powell,"To Find a Stand,"386-401.

17.严格来说，还有一个因素—由于当时交通的限制，医生的服务是“不可分的”。虽然一个贫穷的农村地区可能无法养活一名训练有素的医生，但可以想象的是，如果医生在现代汽车和公路的帮助下可以覆盖八个这样的地区，那么它就可以养活八分之一的医生。但是，由于当时的交通十分原始，社区没有机会选择一个训练有素、价格较高的医生的一小部分，而只能选择一个训练不足、价格较低的医生的全部服务。

18.Benjamin Rush,"Observations on the Duties of a Physician,and the Methods of Improving Medicine;Accommodated to the Present State of Society and Manners in the United States,"in Medical Inquiries and Observations (Philadelphia:J.Conrad,1805),390.

19.Richard Dunlop,Doctors of the American Frontier (Garden City,N.Y:Double-day,1962),129-130.

20.Boston Medical and Surgical Journal 15 (November 30,1836),273.

21.Ivan Waddington,"The Development of Medicine as a Modern Profession,"in A Social History of the Biomedical Sciences,ed.Massimo Piattelli-Palmarini (Milan:Franco Maria Ricci,forthcoming).

22.关于间接价格的一般讨论，见Gary Becker，“A Theory of the Allocation of Time，”The Economic Journal 75 （September 1965），493-517。

23.Rolla M.Tryon，Household Manufactures in the United States，1640-1860 （Chi-cago：University of Chicago Press，1917），243，11.另见Stuart Bruchey，The Roots of American Economic Growth，1607-1861 （New York：Harper&Row，1965），26-31。

24.这些数据摘录自Rosen，Fees and Fee Bills，15-16，其中有许多其他的收费表，同样可以说明问题。

25.对交通和机会成本的直接估计表明，出行成本在大约两英里处超过了基本咨询费。我对该数据的计算见“Medicine，Economy and Society in Nineteenth-Centu-ry America，”Journal of Social History 10 （Summer 1977），604-605。

26.Samuel C.Busey,Personal Reminiscences and Recollections...(Washington,D.C.,1895),157-158.

27.Thomas N.Bonner,Medicine in Chicago,1850-1950 (Madison,Wis.:American Historical Research Center,1957),200.

28.Ibid.

29.Rosen,Fees and Fee Bills,30,41.

30.O.Larsell,The Doctor in Oregon:A Medical History (Portland,Ore.:Binsford&Mort,1947),160.

31.U.S.Bureau of the Census，Historical Statistics，11-12.另见 Adna F.Weber，The Growth of Cities in the Nineteenth Century （New York：Macmillan，1899）。

32.American Medical Association,Committee on Social Insurance,Statistics Re-garding the Medical Profession (Chicago:American Medical Association,1916),38-39.

33.Victor C.Vaughan,A Doctor's Memories (Indianapolis:Bobbs-Merrill,1926),269.

34.铁路对带来远距离病人的作用，见Helen Clapesattle，The Doctors Mayo （Minneapolis：University of Minnesota Press，1941），348-353。关于医生与铁路的关系的进一步讨论，见第六章。

35.Samuel Hays，“Introduction” to Building the Organizational Society，ed.Jerry Israel （New York：Free Press，1972），9-10.关于改变运输成本的问题，见George Rogers Taylor，The Transportation Revolution （New York：Rinehart，1951），尤其是Allen Pred，Urban Growth and the Circulation of Information （Cambridge：Harvard University Press，1973）。

36.John Brooks,Telephone:The First Hundred Years (New York:Harper&Row,1976),65;Marion May Dilts,The Telephone in a Changing World (New York:Long-mans Green,1942),9.

37.Clapesattle,The Doctors Mayo,135-136.

38.Verlin C.Thomas,The Successful Physician (Philadelphia:Saunders,1923),146.

39.George Kessel，“Would Not Practice Without an Auto，”Journal of the American Medical Association（以下简称JAMA）50 （March 7，1908），814.

40.J.A.Bowling,"Testimony from the Southwest,"JAMA 46 (April 21,1906),179.

41."A Compilation of Automobile Statistics," JAMA 54 (April 9,1910),1273-1274.

42.H.A.Stalker,"The Automobile as a Physician's Vehicle,"JAMA 52 (March 7,1908),812.

43.C.A.Hibbert，“Transient Flat Life Requires Physician to Cover Wide Territo-ry，” JAMA 58 （April 6，1912），1080.对该话题的更多论述可参见Lewis Mayers and Leonard V.Harrison，The Distribution of Physicians in the United States （New York：General Education Board，1924），以及Michael L.Berger，“The Influence of the Au-tomobile on Rural Health Care，1900-1929，” Journal of the History of Medicine and the Allied Sciences 28 （October 1973），319-335.

44.Tryon,Household Manufactures,275-276,291-293.

45.Antonio Ciocco and Isidore Altman,"The Patient Load of Physicians in Private Practice,A Comparative Statistical Study of Three Areas," Public Health Reports 58 (September 3,1943),1329-1351.

46.Gerald N.Grob，Mental Institutions in America：Social Policy to 1875 （New York：Free Press，1973）.有关这些发展，另见David J.Rothman，The Discovery of the Asylum：Social Order and Disorder in the New Republic （Boston：Little，Brown，1971），以 及 Andrew T，Scull.Decarceration：Community Treatment and the Deviant—A Radical View （Englewood Cliffs，N.J.：Prentice-Hall，1977），15-40。

47.Michel Foucault,Madness and Civilization:A History of Insanity in the Age of Reason (London:Tavistock Publications,1967).

48.Grob，Mental Institutions in America，135.Grob援引了Samuel Woodward的抱怨，说他的收入大幅减少，因为他声称自己在私人诊所的年薪是5000美元。但如果他确实赚了这么多，那也是极不寻常的；按照当时的行业标准，这些是高薪职位。

49.监护人员在1844年成立了一个独立的专业协会，后来又回绝了美国医学会要求建立联系的尝试。见Grob，Mental Institutions in America，147-150。

50.关于1873年，见J.M.Toner，“Statistics of Regular Medical Associations and Hospitals of the United States，”Transactions of the American Medical Association 24 （1873），314-333；关于之后的情况，见U.S.Bureau of the Census，Historical Statis-tics，78；这一时期各州的调查报告，见“Twenty-five Years’ Growth of the Hospital Field，”National Hospital Record 7 （September 1903），23-27。

51.U.S.Bureau of the Census，Historical Statistics，41.关于家庭结构，见William J.Goode，World Revolution and Family Patterns （New York：Free Press，1963），70-76；Frank Furstenberg，“Industrialization and the American Family：A Look Backward，”American Sociological Review 31 （June 1966），326-337；and Edward Shorter，The Making of the Modern Family （New York：Basic Books，1975）。

52.Bernard Farber,Guardians of Virtue:Salem Families in 1800 (New York:Basic Books,1972),46;Richard Sennett,Families Against the City:Middle Class Homes of Industrial Chicago,1872-1890 (Cambridge:Harvard University Press,1970),79.

53.Henry Hurd,"The Hospital as a Factor in Modern Society,"The Modern Hospi-tal 1 (September 1913),33.

54.Morris Vogel，“Boston’s Hospitals，1870-1930：A Social History，”（Ph.D.diss.，University of Chicago，1974），188-199.另见John Modell and Tamara K.Hareven，“Urbanization and the Malleable Household：An Examination of Boarding and Lodg-ing in American Families，” Journal of Marriage and the Family 35 （1973），467-479。Modell和Hareven指出，1790年至1970年间，一人之家在总家庭中的比例从3.7%上升到20%。

关于英国的情况，参见Brian Abel-Smith，The Hospitals，1800-1948：A Study in Social Administration in England and Wales （Cambridge：Harvard University Press，1967），141。

55.Talcott Parsons and Renée Fox,"Illness,Therapy and the Modern Urban Fami-ly,"Journal of Social Issues 8 (1952),31-44.

56.New York Times,December 31,1900.

57.转引自Scull，Decarceration，15。

58.Dr.Henry B.Hemenway,"Discussion," Bulletin of the American Academy of Medicine 10 (1909),635.

59.S.W.F.Holloway,"Medical Education in England,1830-1858:A Sociological Analysis,"History 49 (1964),299-324.

60.Ibid.

第三章 专业权威的巩固（1850—1930）

1.Samuel Gross,The Autobiography of Samuel Gross (Philadelphia:Saunders,1893),I:93.

2.Arpad Gerster,Recollections of a New York Surgeon (New York:Paul B.Hoeber,1917),162.

3.J.Marion Sims,The Story of My Life (New York:Appleton,1889),116.

4.Anne R.Burr,Weir Mitchell:His Life and Letters (New York:Duffield and Com-pany,1929),43.

5.[Worthington Hooker]，“Report of the Committee on Medical Education，”Transactions of the American Medical Association 4 （1851），420-423.后来在1882年发表的一项研究涵盖了58所学院和自1825年以来毕业的39054名校友，给出了大致相似的比例：9.2%的人从事医学，21%的人从事神学，19.7%的人从事法律。截至1880年，医学院的学生拥有学士学位的人数少于法学院或神学院的学生。见Charles McIntyre，“The Percentage of College-Bred Men in the Medical Profession，”Medical Record 22 （December 16，1882），681。

6.Editorial,"American vs.European Medical Science,"Medical Record 4 (May 15,1869),133.

7.Fred B.Rogers,"General John Beatty (1749-1826):Patriot and Physician,"Bul-letin of the History of Medicine 32 (January-February 1958),39.

8.关于在国会任职的医生名单，见“Appendix，”in James G.Burrow，AMA：Voice of American Medicine （Baltimore：Johns Hopkins Press，1963），405-407；另见“Doc-tors in Government，”JAMA 163 （February 2，1957），361-364。

9.“The Pecuniary Condition of the Medical Profession in the United States，”Bos-ton Medical and Surgical Journal 4 （February 15，1831），9，引用了《基督教考官》（Christian Examiner）上的一篇文章。

10.Sims,Story of My Life,192.

11.Edward C.Atwater,"The Medical Profession in a New Society,Rochester,New York (1811-60),"Bulletin of the History of Medicine 47 (May-June 1973),229.

12.[Lemuel Shattuck,N.P.Banks,Jr.,and Jehiel Abbott],Report of a General Plan for the Promotion of Public and Personal Health (Boston:Dutton and Wentworth,1850),59.

13.Edgar Martin，The Standard of Living in 1860 （Chicago：University of Chicago Press，1942），394.1853年11月8日的《纽约时报》上刊登了一个“中等生活水平”的工薪族四口之家的预算，总支出为600美元。Martin说，律师和医生“在乡村地区似乎每年能获得1000美元左右的收入，在城市则为2000美元”，但没有提供来源或文献。这些数字似乎很高，至少对医生来说是这样。

14.U.S.Bureau of the Census,Historical Statistics of the United States,Colonial Times to 1970 (Washington,D.C.:U.S.Department of Commerce,1975),165.

15.Chester Wright，转引自Martin，Standard of Living in 1860，394。

16.M.E.Pickard and R.C.Buley,The Midwest Pioneer,His Ills,Cures,and Doctors (Crawfordsville,Ind.:Banta,1945),161.

17."A Legion of Leeches," Detroit Review of Medicine and Pharmacy 6 (January 1871),19.

18.B.Joy Jeffries,"Reestablishment of the Medical Profession [Part 2]," Boston Medical and Surgical Journal 118 (June 21,1888),613.

19.C.R.Mabee，The Physician’s Business and Financial Adviser，5th ed.（Cleveland：Continental Publishing，1901），170.Mabee在第185页引用了一份无法核实的纽约杂志，据说医生的平均收入不超过900美元。

20.D.W.Cathell,The Physician Himself (Philadelphia:F.A.Davis),1890 ed.,276;1905 ed.,379.

21.Editorial,"Does It Pay to Be a Doctor?"JAMA 42 (January 23,1904),247.

22.U.S.Bureau of the Census,Historical Statistics,168.

23.G.F.Shears，“Making a Choice，” Cosmopolitan 34 （April 1903），654.转 引 自Gerald E.Markowitz and David Karl Rosner，“Doctors in Crisis：A Study of the Use of Medical Education Reform to Establish Modern Professional Elitism in Medicine，”American Quarterly 25 （March 1973），83-107。

24.Cathell,Physician Himself (1890),80,83.

25.Ibid.(1882),34.

26.这个例子是Sartre的。见Erving Goffman，The Presentation of Self in Everyday Life （Garden City，N.Y.：Doubleday，1959），33。

27.Cathell,Physician Himself (1890),94.

28.Ibid.,97.

29.Ibid.,143.

30.Ibid.,242.

31.Gerster,Recollections,163.

32.Jeffries，“Reestablishment of the Medical Profession [Part 2]，”614；另见idem，“Reestablishment of the Medical Profession [Part I]，” Boston Medical and Surgical Journal 1118 （June 14，1888），589-593。

33.Cathell,Physician Himself (1890),148.

34.Charles Rosenberg,"The Practice of Medicine in New York A Century Ago,"Bulletin of the History of Medicine 41 (May-June 1967),225-228.

35.John Shaw Billings，Selected Papers （[Chicago]：Medical Library Association，1965），19l；William Rothstein，American Physicians in the Nineteenth Century （Balti-more：Johns Hopkins Press，1972），提出了这一论点。

36.W.J.Reader,Professional Men:The Rise of the Professional Classes in Nine-teenth-Century England (New York:Basic Books,1967),47.

37.Billings,Selected Papers,191.

38.Nathan Smith Davis,History of the American Medical Association,from Its Or-ganization to January,1855 (Philadelphia,1855),37-38.

39.S.Oakley Vanderpoel,in Alfred C.Post et al.,An Ethical Symposium (New York:Putnam,1883),37-38.

40.James Howard Means,The Association of American Physicians (New York:Blakiston,1961),10.

41.Mancur Olson，The Logic of Collective Action （Cambridge：Harvard University Press，1965）.我在这里放弃了“公共利益”一词，因为它只会造成混淆，尽管严格意义上是正确的。

42.George W.Corner,Two Centuries of Medicine:A History of the School of Med-icine,University of Pennsylvania (Philadelphia:Lippincott,1965),32-34;Cecil K.Drinker,Not So Long Ago (New York:Oxford University Press,1937),150-151.

43.Rush Van Dyke，Valedictory Address to Graduates of Philadelphia College of Medicine，1849 （Philadelphia，1849），9-10；转引自Henry B.Shafer，The American Medical Profession，1789 to 1850 （New York：Columbia University Press，1937），153-154。

44.Harvey Wickes Felter,History of the Eclectic Medical Institute (Cincinnati:Pub-lished for the Alumni Association,1902),39-42.

45.Chauncey D.Leake,ed.,Percival's Medical Ethics (Baltimore:Williams,1927),Appendix III,225-235.

46.Cathell,Physician Himself (1890),184-186.

47.Max Weber，Economy and Society，tr.Guenther Roth and Claus Wittich （New York：Bedminster Press，1968），I：56；III：164.对于相反阐释的评论和分析，见Peter Berger，“The Sociological Study of Sectarianism，” Social Research 21 （1954），467-485。

48.Sidney E.Ahlstrom，A Religious History of the American People （New Haven：Yale University Press，1972），472-487，1019-1029.另见David Edwin Harrell，Jr.，All Things Are Possible：The Healing and Charismatic Revivals in America （Bloomington，Ind.：Indiana University Press，1975）。

49.Richard Niebuhr,The Social Sources of Denominationalism (New York:Holt,1929).

50.Bryan R.Wilson,Sects and Society (Berkeley:University of California Press,1961),354.

51.关于一位支持者对顺势疗法学说的详细阐述，见Harris Coulter，Divided Leg-acy：A History of the Schism in Medical Thought （Washington，D.C.：McGrath Pub-lishing Co.，1973），esp.Chap.1。

52.Martin Kaufman，Homeopathy in America：The Rise and Fall of a Medical Here-sy （Baltimore：Johns Hopkins Press，1971）；Coulter，Divided Legacy，101-104.Coulter呈现的一些证据表明，顺势疗法者的收入比普通医生高。

53.Joseph Kett,The Formation of the American Medical Profession (New Haven,Conn.:Yale University Press,1968).

54.Coulter，Divided Legacy，204.最初发表于1842年的那篇经典的批评文章，见Oliver Wendell Holmes，“Homeopathy and its Kindred Delusions，”in Medical Essays，1842-1882 （Boston：Houghton-Mifflin，1892）。

55.Kaufman,Homeopathy in America,63-92.

56.Kett,Formation of the American Medical Profession,185-86;J.M.Toner,"Tab-ulated Statistics of the Medical Profession of the United States," Transactions of the American Medical Association 22(1871),155;JAMA 79 (August 23,1913),600.

57.H.R.Hopkins,in Post et al.,Ethical Symposium,184.

58.Donald E.Konold,A History of American Medical Ethics,1847-1912 (Madison,Wis.:State Historical Society of Wisconsin,1962),26.

59.New York Times,May 28,1873.

60.Kaufman,Homeopathy in America,93-109.

61.Coulter,Divided Legacy,328-391.

62.William Ely in Post et al.,Ethical Symposium,12.

63.Rothstein,American Physicians in the Nineteenth Century,304.

64.Lawrence M.Friedman,"Freedom of Contract and Occupational Licensing,1890-1910:a Legal and Social Study," California Law Review 53 (May 1965),494-497.

65.Ibid.,500-512.

66.Bonner,Medicine in Chicago,208.

67.有11个州只要求进行一场考试；10个州在通过考试和提交有效的文凭之间提供选择。“Laws Regulating the Practice of Medicine in the Various States and Ter-ritories of the United States，”JAMA 37 （November 16，1901），1318，这篇文章提供了有各州法律的表格。

68.Harold W.Eickhoff,"The Organization and Regulation of Medicine in Mis-souri,1883-190l." (Ph.D.diss.,University of Missouri,1964),36-40,82,116-122,145-148,274-276.

69.Perry H.Millard,"The Propriety and Necessity of State Regulation of Medical Practice,"JAMA 9 (October 15,1887),491.

70.T.A.Bland,"The Medical Trust,"The Arena 19 (1898),520-526;B.O.Flower,"Restrictive Medical Legislation and the Public Weal,"ibid.,781-809;Herbert Spen-cer,Social Statics (London:John Chapman,1851),372-395;Henry James,ed.,Letters of William James (Boston:Atlantic Monthly Press,1920),II:67.

71.129 U.S.114.另 见 Frances P.DeLancy，The Licensing of Professions in West Virginia （Chicago：Foundation Press，1938）。

72.170 U.S.189;Friedman,"Freedom of Contract and Occupational Licensing,"493ff.

73.John A.Wyeth,"President's Address,"JAMA 38 (June 14,1902),1555.

74.Rothstein,American Physicians of the Nineteenth Century,323.

75."Medical Education in the United States," JAMA 79 (August 19,1922),629,632-633.

76.A.T.Still,The Autobiography of A.T.Still (Kirksville,Mo.:self-published,1897),286-287;Eickhoff,"The Organization and Regulation of Medicine in Mis-souri,"185-200.

77.Edwin Franden Dakin,Mrs.Eddy (New York:Grosset and Dunlap,1929),115.

78.“The Organization of the Medical Profession，” JAMA 38 （January 1，1902），13.另见ibid.（January 25，1902），250-251；ibid.（February 1，1902），324-325；ibid.（February 8，1902），400；ibid.（February 15，1902），460-461；ibid.（February 22，1902），514-515；ibid.（March 1，1902），584-585。

79."Preliminary Report of the Committee on Organization," JAMA 36 (May 25,190l),1450.

80.对各州的分析，见J.N.McCormack，“An Epitome of the History of Medical Organization in the United States，”JAMA 44 （April 15，1905），1213-1218.

81.Burrow,AMA,49-51.

82.Richard Hofstadter,The Age of Reform (New York:Random House,1955),148-164.

83.F.H.Todd,"Organization,"JAMA 39 (October 25,1902),1061.

84.关于医疗事故诉讼的增加，见Andrew A.Sandor，“The History of Profes-sional Liability Suits in the United States，” JAMA 163 （February 9，1957），459-466。Sandor的数据只提到了上诉判决，因此很不确凿；但是，医生对诉讼关注度的增加似乎证明了他的观点。关于地方性法规，见Gramm v.Boener，56 Ind.497 （1877）以及Small v.Howard，128 Mass.131，35 Am.Rep.363 （1880）。关于医疗事故辩护基金，见“Organized Medical Defense，”JAMA 38 （January 4，1902），37，43；“The Var-ied Functions Possible in the County Medical Society，” JAMA 44 （March 18，1905），881-882；Walter L.Burrage，A History of the Massachusetts Medical Society，1787-1922 （Norwood，Mass：private printing，1923），452；Oliver Garceau，The Political Life of the American Medical Association （Cambridge：Harvard University Press，1941），103-104。

85.U.S.Bureau of the Census,Historical Statistics,76.

86.Lawrence Veysey,The Emergence of the American University (Chicago:Univer-sity of Chicago Press,1965);Joseph Ben-David and Awraham Zloczower,"Universities and Academic Systems in Modern Societies,"Archives of European Sociology 3 (962),71-75.

87.Annual Report of the President of Harvard College,1869-70,18;Annual Report of the President of Harvard College,1871-72,25-26.

88.Frederick C.Shattuck and J.Lewis Bremer,"The Medical School,1869-1929,"in The Development of Harvard University,ed.Samuel Eliot Morison (Cambridge:Harvard University Press,1930),556-557;Hugh Hawkins,Between Harvard and America:The Educational Leadership of Charles W.Eliot (New York:Oxford Univer-sity Press,1972),60-61;Henry Bigelow,Medical Education in America (Cambridge:Harvard University Press,1871).

89.Annual Report of the President of Harvard College,1870-71,20.

90.Annual Report of the President of Harvard College,1879-1880,25,33-34;Shat-tuck and Bremer,"The Medical School,"560-561.

91.Corner,Two Centuries,142-151.

92.Martin Kaufman,American Medical Education:The Formative Years,1765-1910 (Westport,Conn.:Greenwood Press,1976),155-156.

93.Alan M.Chesney,The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine,vol.I,Early Years,1867-1893 (Baltimore:Johns Hopkins Press,1943).

94.Simon Flexner and James Thomas Flexner,William Henry Welch and the Hero-ic Age of American Medicine (New York:Dover,1966);Donald Fleming,William H.Welch and the Rise of Modern Medicine (Boston:Little,Brown,1954).

95.见Markowitz and Rosner，“Doctors in Crisis，”95。

96.Mary R.Walsh,"Doctors Wanted:No Women Need Apply" (New Haven,Conn.:Yale University Press,1977),176-193.

97.Arthur Dean Bevan,"Cooperation in Medical Education and Medical Service,"JAMA 90 (April 14,1928),1173-1177.

98.见 Table I，“Statistics of Medical Colleges in the United States and Canada”，收录于美国医学会关于医学教育的年度报告，JAMA 37 （1901），758-759；39 （1902），568-569；41 （1903），452-453；43 （1904），504-505；45 （1905），566-567；47 （1906） 592-593；49 （1907），588-589；51 （1908），586-587；53 （1909），546-549。

99.Abraham Flexner,Medical Education in the United States and Canada,Bulletin no.4 (New York:Carnegie Foundation for the Advancement of Teaching,1910).

100.Ibid.,11.

101."Medical Education—Progress of Twenty-Two Years," JAMA 79 (August 19,1922),660-661;"State Requirements of Preliminary Education," JAMA 79 (August 19,1922),658.

102.Ernest V.Hollis，Philanthropic Foundations and Higher Education （New York：Columbia University Press，1938），211-217.Hollis估计，到1936年，各基金会对医学教育和研究的总投入为1.54亿美元。关于通才教育委员会的作用，见Daniel Fox，“Abraham Flexner’s Unpublished Report：Foundations and Medical Education，1909-1928，”Bulletin of the History of Medicine 54 （Winter 1980），475-496。

103.一些马克思主义者进一步认为，由于科学医学的意识形态功能，资本家对科学医学的成功有着显著的兴趣。见Howard Berliner，“A Larger Perspective on the Flexner Report，” International Journal of Health Services （1975），573-592，以及E.Richard Brown，Rockefeller Medicine Men：Medical Care and Capitalism in America （Berkeley：University of California Press，1978）。Berliner 在他“更广的视角”中首先指出，科学医学将身体视为一台机器，这一构想与其他资本主义观念听上去极其相似。然后，他将科学医学与细菌学革命之前的“对抗疗法”如放血，联系起来，最后提出，资本主义在这种医学的胜利中有利可图，因为它发挥了合法化和资本积累的不可或缺的功能。遗憾的是，许多人认为这是马克思主义，更遗憾的是，许多马克思主义者认真对待它。关于Brown著作的更多内容，见第六章。

104.Corner，Two Centuries，187.对一个临床教授来说，一个职位的平均价值“可能是”10000美元，“原因是它带来了业务”。Ross V.Patterson to Abraham Flexner，March 31，1909 （Flexner papers，Box 19，Library of Congress）.

105.Fleming,William H.Welch,177-178.

106.Hollis，Philanthropic Foundations，211-212.Brown，Rockefeller Medicine Men，将全职要求视为法人资本主义在医疗保健领域的“进入楔子”；不那么情绪化的讨论，见Fox，“Flexner’s Unpublished Report，”484-487。

107.Joseph C.Aub and Ruth K.Hapgood,Pioneer in Modern Medicine:David Linn Edsall of Harvard (n.p.:Harvard Medical Alumni Association,1970).

108.Fox,"Flexner's Unpublished Report,"489-490.

109.Rosemary Stevens,American Medicine and the Public Interest (New Haven,Conn.:Yale University Press,1971),116-120;J.A.Curran,"Internships and Resi-dencies:Historical Background and Current Trends," Journal of Medical Education 34 (September 1959),878-889.

110.Walsh,"Doctors Wanted:No Women Need Apply," 178-267;Carol Lopate,Women in Medicine (Baltimore:Johns Hopkins Press,1968);Flexner,Medical Educa-tion,178-179.

111.Numa P.G.Adam,"Sources of Supply of Negro Health Personnel:Section A:Physicians,"Journal of Negro Education 6 (July 1937),468.

112.Collier's Weekly,June 11,1910 (Flexner papers,Box 19,Library of Congress).113.Flexner,Medical Education,16,45-46.

114.Raymond Pearl,"Distribution of Physicians in the U.S.," JAMA 84 (April 4,1925),1024-1027.

115.American Medical Association,Committee on Social Insurance,Statistics Re-garding the Medical Profession (Chicago:American Medical Association,1916),38-39.

116.Samuel Hopkins Adams,"The Vanishing Country Doctor," with sequels,Ladies'Home Journal 40 (October 1923),23ff;ibid.(November 1923),26ff;ibid.41 (February 1924),31ff;William Allen Pusey,"The Disappearance of Doctors from Small Towns,"JAMA 88 (February 12,1927),505-506.

117.Lewis Mayers and Leonard V.Harrison,The Distribution of Physicians in the United States (New York:General Education Board,1924),47-48.

118.U.S.Bureau of the Census,Historical Statistics,76.

119.Louis S.Reed,The Healing Cults,A Study of Sectarian Medical Practice:Its Ex-tent,Causes,and Control (Chicago:University of Chicago Press,1932),1-4,24-26,50-54.

120.Selwyn D.Collins,"Frequency and Volume of Doctors'Calls Among Males and Females in 9,000 Families,Based on Nation-Wide Periodic Canvasses,1928-31,"Public Health Reports 55 (November 1,1940),1987-1988.

121.James Harvey Young,The Toadstool Millionaires (Princeton,N.J.:Princeton University Press,1961),167-170.

122.Sarah Stage,Female Complaints:Lydia Pinkham and the Business of Women's Medicine (New York:Norton,1979),89-90,105-106,130-131.

123.A[braham] Jacobi，“Proprietary Medicines，” JAMA 97 （September 29，1906），978.另见Richard C.Cabot，“The Physician’s Responsibility for the Nostrum Evil，”ibid.，982。

124.“Secret Nostrums and the Journal，”JAMA 34 （June 2，1900），1420.另见“Rela-tion of Pharmacy to the Medical Profession，”ibid.34 （April 21，1900），986-988；ibid.34 （April 28，1900），1049-1051；and sequels。

125.Edward Bok,"The Patent Medicine Curse," Ladies'Home Journal 21 (May 1904,18).

126.Samuel Hopkins Adams,The Great American Fraud (n.p.:Collier&Son,1905 and 1906),39.

127.Edward Bok,"Pictures that Tell Their Own Stories,"Ladies'Home Journal 22 (September 1905),15;Stage,Female Complaints,140,160-162.

128.Adams,Great American Fraud,60.

129.Ibid.,84.

130.Austin Smith,"The Council on Pharmacy and Chemistry,"in Morris Fishbein,A History of the American Medical Association,1847 to 1947 (Philadelphia:Saunders,1947),86.

131.Editorial,"A Great Paper Attempts the Impossible,"JAMA 58 (April 13,1912),118.

132.Jacob A.Goldberg,"The Advertising Physician," Hygeia 1 (August 1923),308-311.

133.Stage,Female Complaints,198.

134.R.V.Pierce,The People's Common Sense Medical Adviser in Plain English;or,Medicine Simplified,99th ed.[?] (Buffalo,N.Y.:World's Dispensary Medical Associa-tion,1918),379.

135.Smith,"Council on Pharmacy and Chemistry,"871.

136.Peter Temin,Taking Your Medicine:Drug Regulation in the United States (Cambridge:Harvard University Press,1979),Chap.2.

137.这段引文和以下其他引文都来自Rima D.Apple，“‘To Be Used Only Un-der the Direction of a Physician’：Commercial Infant Feeding and Medical Practice，1870-1940，”Bulletin of the History of Medicine 54 （Fall 1980），402-417。

138.Ibid.,412.

139.Erwin H.Ackerknecht,Therapeutics from the Primitives to the 20th Century (New York:Hafner Press,1973),128-136.

140.Rothstein,American Physicians of the Nineteenth Century,266.

141.Irving Fisher,Report on National Vitality:Its Wastes and Conservation,Bulle-tin no.30 of the Committee of One Hundred on National Health (Washington,D.C.:U.S.Government Printing Office,1909),7,66.

142.JAMA 60 (June 21,1913),1996.

143.Stanley J.Reiser,Medicine and the Reign of Technology (Cambridge:Cam-bridge University Press,1978),43,38.

144.Ibid.,68.

145.Shryock,Development of Modern Medicine;H.J.Parish,A History of Immuni-zation (Edinburgh:E.&S.Livingstone,1965).

146.John B.McKinlay and Sonja M.McKinlay，“The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States，” Health and Society 55 （Summer 1977），405-428.在“医疗干预（化疗或预防）年份”列表中，McKinlays列出了1930年的白喉（类毒素）和1948年的伤寒（氯霉素）。他们写道，白喉和伤寒“在医疗干预之后，其死亡率的下降可以忽略不计”（421）。难道他们没有听说过白喉抗毒素或伤寒疫苗吗？

147.关于破伤风和白喉的证据，见Parish，History of Immunization，131，166-169；另见Edgar Sydenstricker，Health and Environment （New York：McGraw-Hill，1933）；C.-E.A.Winslow，Health Survey of New Haven （New Haven：[Community Chest] 1928），374-381。

148.John Lovett Morse,"Recollections and Reflections on Forty-Five Years of Ar-tificial Infant Feeding,"Journal of Pediatrics 7 (September 1935),324.

149.Thomas E.Cone,Jr.,History of American Pediatrics (Boston:Little,Brown,1979),138.

150."Discussion,"Minnesota Medicine 6 (July 1923),445.

151.这些言论见于Victor C.Vaughan，“The Promotion of Periodic Health Exami-nations by the Medical Profession，”AMA Bulletin 16 （March 15，1923），296.Vaughan在他的自传中对这些经历做了详细的描述，A Doctor’s Memories （Indianapolis：Bobbs-Merrill，1926），375-379，397-399。

152.Christopher Lasch，The Culture of Narcissism （New York：Norton，1979），228-229，以及idem，“Life in the Therapeutic State，”The New York Review of Books，June 12，1980，24-32。

153.R.G.Leland,"Income from Medical Practice," JAMA 96 (May 16,1931),1687-1691;U.S.Bureau of the Census,Historical Statistics,176;Maurice Leven,In-comes of Physicians (Chicago:University of Chicago Press,1932),20,105-106;Milton Friedman and Simon Kuznets,Income from Independent Professional Practice (New York:National Bureau of Economic Research,1945),67-68,84.

154.Friedman and Kuznets,Income from Independent Professional Practice,14-15.155.George S.Counts,"The Social Status of Occupations:A Problem in Vocational Guidance,"The School Review 33 (January 1925),16-27;George W.Hartmann,"The Prestige of Occupations,A Comparison of Educational Occupations and Others,"Personnel Journal 12 (October 1934),144-152.

156.Rothstein，American Physicians in the Nineteenth Century，他主张以下的观点，即明显有效的疗法解释了医学“从宗派到科学”的转变，但也提供了许多有说服力的证据来反对他自己的立场。治疗方法的创新似乎太少、太晚，没有办法解释宗派的衰落。Rothstein 强调，直到19世纪90年代，行医者仍漠视和抵制细菌学；然后是白喉抗毒素出现了，很快，这个专业就转变了。这个说法很难让人接受。尽管Rothstein 的书对医学会和医学宗派的分析具有启发性，是非常宝贵的，但他对转变的分析没有注意到社会中更广泛的变化。

对于第二种观点，见Jeffrey L.Berlant，Profession and Monopoly：A Study of Medicine in the United States and Great Britain （Berkeley：University of California Press，1975）。

157.Karl Polanyi,The Great Transformation (Boston:Beacon Press,1957),152.

第四章 医院的重构

1.关于美国和其他地方的医生、病人、医院之间关系的比较，见Milton I.Ro-emer and Jay W.Freidman，Doctors in Hospitals （Baltimore：John Hopkins Press，1971），49-61。关于更多对本章极有用的一般性比较研究，见William Glaser，“American and Foreign Hospitals：Some Sociological Comparisons，”in The Hospital in Modern Society，ed.Eliot Freidson （New York：Free Press，1963），37-72，以 及Glaser被忽视的卓著，Social Settings and Medical Organization：A Cross-National Study of the Hospital （New York：Atherton，1970）。关于截至1885年的跨国比较而言，见Lewis S.Pilcher，“On the Organization of the Surgical Staff in General Hospi-tals，”Annals of Surgery 2 （1885），389-408。

2.本章的分析处理的是普通医院，而不是精神病院，除非在二者的对照有启发意义的地方。

这一章的形式与1976年至1977年间我所撰写和流布的内容几乎相同，并构成了我1977年提交的哈佛大学博士论文的一部分。从那时起，出现了一些关于医院的优秀新作。尤其参见新著David Rosner，A Once Charitable Enterprise （Cam-bridge：Cambridge University Press，forthcoming），以及Morris Vogel，The Invention of the Modern Hospital：Boston，1870-1990 （Chicago：University of Chicago Press，1980）。我看到了David Rosner的部分写作草稿和Morris Vogel论文的未发表版本；因此只引用了这些。另见 Charles E.Rosenberg，“Inward Vision and Outward Glance：The Shaping of the American Hospital，1880-1914，” in Social History and Social Policy，ed.David J.Rothman and Stanton Wheeler （New York：Academic Press，1981）。我注意到这本著作时已经太晚了，以至于在此未能使用。

3.组织的历史社会学在很大程度上仍是一个未经发展的学科，或者至少是未经整合的学科。关于法人企业结构的变化，见Alfred Chandler，The Visible Hand （Cambridge：Harvard University Press，1977）。关于大学的历史，见Lawrence Vey-sey，The Emergence of the American University （Chicago：University of Chicago Press，1965）。

4.“共同体的”和“相关的”是帕森斯对韦伯术语Vergemeinschaftung和Verge-sellschaftung的翻译，这对术语又来自Tonnies。见Max Weber，The Theory of Social and Economic Organization （New York：Oxford University Press，1947），136-139。

5.John P.Davis,Corporations,ed.Abram Chayes (1905;reprint ed.,New York:Capricorn Press,1961),xix.

6.George Rosen，“The Hospital：Historical Sociology of a Community Institution，”in Freidson ed.，The Hospital in Modern Society，10.另见Rotha Mary Clay，The Medi-eval Hospitals of England （London：Methuen，1909），143-157。

7.David J.Rothman，The Discovery of the Asylum （Boston：Little，Brown，1971），42-43.“衍生的”和“设计的”这两个词出自John Thompson and Grace Goldin，The Hospital：A Social and Architectural History （New Haven，Conn：Yale University Press，1973）。

8.Henry Sigerist,"An Outline of the Development of the Hospital,"Bulletin of the History of Medicine 4 (July 1936),573-581.

9.Rothman，Discovery of the Asylum，3-29，180-205；关于支持从家庭救济转向救济院的论点，见 Philadelphia Board of Charities，“Report of the Committee...”（1827），esp.23-30；[Josiah Quincy]，“Report of the Committee on the Pauper Laws...”（182），9；and John Yates，“Report of the Secretary of State…”（1824），939-963；再版于The Almshouse Experience：Collected Reports （New York：Arno Press，1971）。关于后来的改革，见Robert H.Bremner，From the Depths：The Discovery of Poverty in the United States （New York：New York University Press，1956），46-57。关于从救济院到城市医院的转变，见 Robert John Hunter，The Origin of the Philadelphia General Hospital，Blockley Division （Philadelphia：Rittenhouse Press，1955）；Douglas Carroll，“History of the Baltimore City Hospitals，”Maryland State Medical Journal 15 （January 1966），87-90；（February 1966），46-48；（March 1966），75-78；（April 1966），65-68；（（May 1966），83-85；（June 1966），101-103；（July 1966），17-19；（August 1966），69-71；（September 1966），105-108；（October 1966），89-96；（November 1966），103-111。

Rothman 将救济院与监狱和精神病院联系在一起，并认为其发展的动力在于杰克逊时代的改革者对改造依附者、罪犯和精神病患者的热忱。但正如他自己所承认的那样，转向救济院救济的目的同样是为了通过禁绝穷人的家庭救济来对贫困产生威慑力。赞许救济院的报告显然关注的是它们对救济院外的穷人的影响，而不是对救济院内的穷人的影响。在取消家庭救济的同时，各州也在迫使移民社区为穷人和病人建立自己的机构。惩罚穷人和限制公共支出方面的利益似乎足以解释救济院的流行，因此，Rothman强调康复是发展救济院的动机，似乎把他的论点延伸得太远了。

10.Leonard K.Eaton,New England Hospitals,I790-1837 (Ann Arbor:University of Michigan Press,1957).

11.Benjamin Rush,Medical Inquiries and Observations,2d ed.(Philadelphia:J.Conrad,1805),I:276;John E.Erichsen,On Hospitalism and the Causes of Death After Operations (London:Longmans,1874);James Y.Simpson,"Our Existing System of Hospitalism and Its Effects," Edinburgh Medical Journal 15 (December 1869),523-532;W.Gill Wylie,Hospitals:Their History,Organization,and Construction (New York:Appleton,1877),57-66.

12.Nathaniel I.Bowditch，A History of the Massachusetts General Hospital to Au-gust 5，1851，2nd.ed.with continuation to 1872 （Boston：The Trustees，1872），3-9；Morris Vogel，“Boston’s Hospitals，1870-1930：A Social History.” （Ph.D.diss.，Uni-versity of Chicago，1974），12-18.在1868年圣路易斯城市医院收治的病人中，超过五分之四的人要么单身要么丧偶；只有17.3%的人已婚。Board of Health，Second Annual Report （St.Louis，1869），19.

13.Francis R.Packard,Some Account of the Pennsylvania Hospital (Philadelphia:Engle Press,1938),9.

14.History of the Reading Hospital,1867-1942 ([Reading,Pa.]:The Reading Hos-pital,1942),5.

15.Allan Nevins and Milton Halsey Thomas,eds.,The Diary of George Templeton Strong:The Turbulent Fifties,1850-1859 (New York:Macmillan,1952),92.

16.Hyman Grinstein,The Rise of the Jewish Community of New York,1654-1860 (Philadelphia:Jewish Publication Society of America,1945),155-159,187-188.

17.Robert W.Downie,"Pennsylvania Hospital Admissions,1751-1850:A Survey,"Transactions and Studies of the College of Physicians 32 (1964),25.

18.George Worthington Adams,Doctors in Blue (New York:Collier Books,1961),101-151.

19.Elizabeth C.Hobson，Recollections of a Happy Life （New York：privately print-ed，1914），77-114；对州慈善援助协会中的女士们的描述来自它的第一份年度报告，引自M.Adelaide Nutting and Lavinia L.Dock，A History of Nursing （New York：Putnam，1907），II：370。

20.Jo Ann Ashley,Hospitals,Paternalism,and the Role of the Nurse (New York:Teachers College Press,1976),20.

21.Frederick F.Cartwright,The Development of Modern Surgery (London:Arthur Barker,1967),12-22.

22.Helen Clapesattle,The Doctors Mayo (Minneapolis:University of Minnesota Press,1941),297-338,407,432.

23.S.E.Crocker,"The Invalid in Home and Hospital,"National Hospital Record 2 (March 1899),7-9.

24.Vogel，“Boston’s Hospitals，” 140.布里奇波特市的数字引用自Commission on Hospital Care，Hospital Care in the United States （New York：Commonwealth Fund，1947），545。U.S.Bureau of the Census，Hospitals and Dispensaries：1923，3.

25.林肯医院的早期历史出自Fitzhugh Mullan，White Coat，Clenched Fist：The Po-litical Education of an American Physician （New York：Macmillan，1976），117-121。

26.Vogel,"Boston's Hospitals,"36,15-18;"Children's Hospital,Papers and Clip-pings,1869-1879,"Countway Library,Harvard Medical School.

27.Florence Nightingale,Notes on Hospitals,3rd ed.(London:Longman,Roberts and Green,1863),51-52.

28.Niles Carpenter，Hospital Service for Patients of Moderate Means （Washington，D.C.：Committee on the Costs of Medical Care，1930），23.这些数据基于对隶属美国医院协会的建筑师的调查，他们被要求报告他们在1908、1918和1928年所设计的医院中的床位数。

29.关于病人的早期义务，见Thomas G.Morton，A History of the Pennsylvania Hospital，1751-1895 （Philadelphia：Times Printing House，1895），210；Sidney Gold-stein，“The Social Function of the Hospital，” Charity and the Commons 18 （May 4，1907），162；Talcott Parsons，The Social System （Glencoe，Ill.：Free Press，1951），428-447。

30.S.S.Goldwater,"The Cost of Modern Hospitals," National Hospital Record 9 (November 1905),39-48.

31.Frank Tucker,"The Financial Problem of New York's Hospitals,"Charities 12 (January 2,1904),27-32;"What the Managers of the Hospitals Have to Say About Their Financial Problem,"ibid.,32-46;"Press Comment...,"ibid.,83-85.

32.David Rosner,"Bedside Business:The Transformation of Brooklyn's Hospitals During the Progressive Era."(Unpublished manuscript,Harvard University,1977.)

33.E.H.Lewinski-Corwin,The Hospital Situation in Greater New York (New York:Putnam,1924),121,130.

34.U.S.Bureau of the Census,Hospitals and Dispensaries:1923,4.

35.Albert R.Lamb,The Presbyterian Hospital and the Columbia-Presbyterian Med-ical Center,1868-1943 (New York:Columbia University Press,1955),22-24;Vogel,"Boston's Hospitals,"126-129.

36.Herbert D.Howard,"The Managers and the Superintendent,"National Hospi-tal Record 6 (December 1902),10.

37.J.M.Toner,"Statistics of Regular Medical Associations and Hospitals of the United States,"Transactions of the American Medical Association 24 (1873),314-333;E.H.L.Corwin,The American Hospital (New York:Commonwealth Fund,1946),7.

38.Henry S.Stark,"Hospital Reform in a New Light,"National Hospital Record 10 (February 1907),18-19.

39.Lewis S.Pilcher,"On the Organization of the Surgical Staff in General Hospi-tals,"Annals of Surgery 2 (1885),399.

40.关于医院任命的价值的讨论，见 Michael M.Davis and C.Rufus Rorem，The Crisis in Hospital Finance （Chicago：University of Chicago Press，1932），78-89。

41."The Medical Profession and the Hospitals," Medical Record 45 (January 6,1894),16.

42.Henry C.Burdett,Pay Hospitals and Paying Wards Throughout the World (Phil-adelphia:Presley Blakiston,1880),73;George W.Gay,"Abuse of Medical Charity,"Boston Medical and Surgical Journal 152 (March 16,1905),300;E.W.Cushing,"The Physician and the Private Hospital Patient," ibid.,311;"Private Patients'Liability,"National Hospital Record 8 (October 1904),6.

43.H.D.Niles，“Our Hospitals，” JAMA 38 （March 22，1902），759-761；Bayard Holmes，“The Hospital Problem，”ibid.47 （August 4，1906），320.霍姆斯是1895年芝加哥市长竞选中社会党派的候选人。

44.A.L.Beahan,"Hospitals in the Smaller Towns," Buffalo Medical Journal 41 (1901),187;Laura Lane,"The Individual Private Hospital,"National Hospital Record 10 (July 1907),37ff.

45."Hospitals and General Practitioners," National Hospital Record 10 (March 1907),9;Arpad G.Gerster,"System of American Hospital Economy,"National Hos-pital Record 9 (January 1906),17-19.

46."The City Hospital Issue,"Cincinnati Medical News 1 (November 1944),326-327;Dr.R.Lincoln Graham,"History of the Decay of Medical Opulence,"The Medi-cal Economist,publication of the Federation of Medical Economic Leagues 3 (February 1915),40;S.S.Goldwater,"The Extension of Hospital Privileges to All Practitioners of Medicine,"JAMA 84 (March 28,1925),933-935.

47."Article 3—Need for More Hospitals," National Hospital Record 8 (November 1904),26;Albert J.Ochsner and Meyer J.Sturm,The Organization,Construction and Management of Hospitals (Chicago:Cleveland Press,1909),563.

48.Rosner,"Bedside Business";Corwin,Hospital Situation in Greater New York,45,177;Davis and Rorem,Crisis in Hospital Finance,81;"Hospital Service in the United States," JAMA 98 (June 11,1932),2073;"Hospital Service in the United States,"JAMA 102 (March 31,1934),1014.

49.Roemer and Friedman,Doctors in Hospitals,36-39.

50.Cleveland Hospital Council,Cleveland Hospital and Health Survey (Cleveland:The Council,1920),858,863;Oswald Hall,"The Stages of a Medical Career,"Ameri-can Journal of Sociology 53 (March 1948),331.

51.Oswald Hall,"The Informal Organization of the Medical Profession,"Canadian Journal of Economics and Political Science 12 (February 1946),30-44;Hall,"Stages of a Medical Career,"327-336.

52.Glaser,"American and Foreign Hospitals,"54

53."Hospital Service in the United States" JAMA 94 (March 29,1930),928;Max Sehan,Blacks and American Medical Care (Minneapolis:University of Minnesota Press,1973),72-73.

54.U.S.Bureau of the Census,Historical Statistics of the United States:Colonial Times to 1970 (Washington,D.C.:U.S.Department of Commerce,1975),78.

55.U.S.Bureau of the Census,Hospitals and Dispensaries:1923,25-26 (from Ta-bles 5 and 6).

56.Irving Fisher,"Private Patients in General Hospitals,"National Hospital Record 8 (June 1905),19-25.

57."The Hospital Superintendents on the Hospital Situation in New York,"Chari-ties 12 (February 6,1904),157-161.

58.S.S.Goldwater,"The United States Hospital Field," in Hospital Charities,ed.Henry Burdett (London:The Scientific Press,1906).

59.U.S.Bureau of the Census,Benevolent Institutions,1904,20.

60.George Wilson,"The Hospitals of the National [Capital]," National Hospital Record 9 (May 1906),12.

61.Vogel,"Boston's Hospitals,"83-84.

62.关于对爱尔兰人的排斥，见 Vogel，“Boston’s Hospitals，” 21-22；关于犹太人对非犹太医院的疑虑，见Grinstein，Rise of the Jewish Community of New York，155-159；这段来自俄罗斯犹太人的引文出自Yidische Gazaetten （April 1894），转引 自 Moses Rischin，The Promised City：New York’s Jews 1870-1914 （Cambridge：Harvard University Press，1962），104；Richard C.Cabot，Social Service and the Art of Healing （New York：Moffat，Yard，1909），4-8。

63.Hall,"Stages of a Medical Career,"330.

64.Johan Goudsblom,Dutch Society (New York:Random House,1967),32,124.

65.关于高等教育中种族关系的讨论，以及更广泛的思考，见Christopher Jencks and David Riesman，The Academic Revolution （Garden City，N.Y.：Doubleday，1968），chaps.8 and 9。

66.Glaser,Social Settings and Medical Organization,32-38,74-75.

67.Charles P.Emerson,"The American Hospital Field,"in Hospital Management,ed.Charlotte A.Aikens (Philadelphia:Saunders,1911),2;American Medicine:Testi-mony Out of Court (New York:American Foundation,1937),II:723-724.

68.Glaser,"American and Foreign Hospitals,"39-50.

69.关于医院管理的早期发展，见Michael M.Davis，Hospital Administration：A Career （New York，1929）。关于医生和行政人员之间不断变化的平衡，见Roemer and Friedman，Doctors in Hospitals，118-120；Robert N.Wilson，“The Physician’s Changing Hospital Role，”Human Organization 18 （Winter 1959-1960），177-183.

70.Charles Perrow,"Goals and Power Structures:A Historical Case Study,"in The Hospital in Modern Society,ed.Freidson,12-46;and idem,"The Analysis of Goals in Complex Organizations," American Sociological Review 26 (December 1961),854-866.

第五章 公共卫生的边界

1.C.-E.A.Winslow,"The Untilled Fields of Public Health,"Science 51 (January 9,1920),30.

2.关于公共卫生的方向变化，见Charles V.Chapin，“History of State and Munic-ipal Control of Disease，”in A Half Century of Public Health，ed.Mayzyck P.Ravenal （New York：American Public Health Association，1921），135-137；Barbara Gutmann Rosenkrantz，Public Health and the State：Changing Views in Massachusetts，1842-1936 （Cambridge：Harvard University Press，1972）；James H.Cassedy，Charles V.Chapin and the Public Health Movement （Cambridge：Harvard University Press，1962）；and George Rosen，A History of Public Health （New York：MD Publications，1958），Chap.7。

3.Charles Rosenberg,"Social Class and Medical Care in Nineteenth-Century America:The Rise and Fall of the Dispensary,"Journal of the History of Medicine and the Allied Sciences 29 (January 1974),32-54;Michael M.Davis,Clinics,Hospitals and Health Centers (New York:Harper and Brothers,1927).

4.George F.Shrady，“A Propagator of Pauperism：The Dispensary，” The Forum 23 （June 1897），425；施拉迪从《医学记录》上的一篇文章引用了前述说法；Ag-nes C.Vietor，“The Abuse of Medical Charity：The Passing of the‘Charity’ Hospital and Dispensary，”Boston Medical and Surgical Journal 140 （May 4，1899），419；Davis，Clinics，Hospitals and Health Centers，80-83。

5.Michael M.Davis,Jr.,and Andrew W.Warner,Dispensaries:Their Management and Development (New York:Macmillan,1918),42.

6.Ibid.，46-58；对诊疗所滥用的进一步研究的总结，见Davis，Clinics，Hospitals and Health Centers，53ff；W.S.Thayer，“On Some Functions of the Free Dispensary，”Boston Medical and Surgical Journal 168 （February 6，1913），185-188；玛丽·里士满在第四届医院院长协会年会上的评论，National Hospital Record 6 （March 1903），8-10。

遗憾的是，诊疗所和医生在自己的诊室仅仅作为救济或根据与当地政府的合同为穷人提供的医疗服务的相对份额，我们没有估计数值。因此，我们无法分辨诊疗所的发展是否意味着为穷人提供了更多的免费服务，还是意味着补贴性医疗服务从诊室和家庭中转移出来。如果诊疗所的增加代表免费服务数量的绝对增加，那么它是否也代表了人均服务的增加，或者它只是对穷人数量增加的一种反应？现有的数据看似并不能回答这些问题。

7.Committee on Inquiry into the Department of Health,Charities and Bellevue and Allied Hospitals,Report (New York,1913),532.

8.Editorial，“Too Many Schools，” National Hospital Record 6 （November 1902），33；关于诊所费用的增长，见Davis，Clinics，Hospitals and Health Centers，323-338。

9.关于这里所讨论的事态的最新回顾，见John Duffy，“The American Medical Profession and Public Health：From Support to Ambivalence，”Bulletin of the History of Medicine 53 （Spring 1979），1-22。

10.以下各段，除特别指出其他来源外，均借自John Duffy，A History of Public Health in New York City，1866-1966 （New York：Russell Sage Foundation，1974）；C.-E.A.Winslow，The Life of Hermann M.Biggs （Philadelphia：Lea&Febiger，1929）；Wade W.Oliver，The Man Who Lived for Tomorrow：A Biography of William Hallock Park，M.D.（New York：Dutton，1941）；Jonathan T.Deland，“Hermann Biggs’ Public Health Work and the Medical Profession：New York City and State，1889-1923.” （Unpub-lished B.A.thesis，Committee on History and Science，Harvard University，March 1976）。

11.Board of Health,Annual Report (New York,1893),12-13.

12.W.R.Ingle Dalton，letter，New York Times，November 24，1901.圣路易斯的7名儿童在接受了由市卫生局分发的受污染的白喉抗毒素后，刚刚死于破伤风（New York Times，November 19，1901）。1902年，国会通过了《生物制品管制法》，禁止在没有美国公共卫生局许可的情况下跨州销售此类产品。

13.Daniel M.Fox,"Social Policy and City Politics:Tuberculosis Reporting in New York,1889-1900," Bulletin of the History of Medicine 49 (Summer 1975),169-195;Hermann M.Biggs,"Sanitary Measures for the Prevention of Tuberculosis in New York City and their Results,"JAMA 39 (December 27,1902),1635-1638.

14.Samuel Hopkins Adams,"Tuberculosis:The Real Race Suicide," McClure's 24 (January 1905),234-249.

15.Duffy,Public Health in New York City,244.

16.Leonard P.Ayres,"What American Cities Are Doing for the Health of School Children,"The Annals 37 (March 1911),250-260;Annette Lynch,"Evaluating School Health Programs," in Health Services:The Local Perspective,ed.Arthur Levin (New York:Academy of Political Science,1977),89-92;Mary Ross,"Health Inventory:1934,"Survey Graphic 23 (January 1934),38-40.

17.Chapin,"History of State and Municipal Control of Disease,"140.

18.Cassedy,Chapin and the Public Health Movement,96,100.

19.Charles V.Chapin,How to Avoid Infection (Cambridge:Harvard University Press,1917),61-62.

20.C.-E.A.Winslow,The Evolution and Significance of the Modern Public Health Campaign (New Haven,Conn.:Yale University Press,1923),57,58.

21.Richard H.Shryock,National Tuberculosis Association 1904-1954 (New York:National Tuberculosis Association,1957),130,157-158,170.

22.Davis and Warner，Dispensaries （1918），12-17；Davis，Clinics，Hospitals and Health Centers （1927），15-17.注意后一本书书名用语的变化。

23.John C.Burnham,"Medical Specialists and Movements Toward Social Control in the Progressive Era:Three Examples," in Building the Organizational Society,ed.Jerry Israel (New York:Free Press,1972),19-30.

24.Stanley Joel Reiser,"The Emergence of the Concept of Screening for Disease,"Health and Society 56 (Fall 1978),403-425.

25.Ibid；James A.Tobey，“The Health Examination Movement，” The Nation’s Health 9 （September 1923），610-611，648.对于该信条的激昂陈述，见James A.To-bey，“A Layman’s View of Health Examinations，”Boston Medical and Surgical Journal 191 （November 6，1924），875-878。

26.J.H.J.Upham,"The State Medical Association and the State Board of Health,"AMA Bulletin 16 (February 1923),273.

27."Like Banquo's Ghost the Chicago Public Health Institute Will Not Down,"Illinois Medical Journal 58 (November 1930),313ff;New York Times,April 8,11,and 14,1929.

28.Davis，Clinics，Hospitals and Health Centers，357；George Rosen，“The First Neighborhood Health Center Movement：Its Rise and Fall，”American Journal of Pub-lic Health 61 （August 1971），1620-1637；John D.Stoeckle and Lucy M.Candib，“The Neighborhood Health Center—Reform Ideas of Yesterday and Today，”New England Journal of Medicine 280 （June 19，1969），1385-1390.Stoeckle和Candib试图为1960年代的街区卫生中心寻找先例，但他们没有明确指出早期的卫生中心主要不是提供医疗服务；他们的发起人发誓不会与当地医生竞争。另一方面，1960年代的项目试图在私人医生几乎消失的地区提供综合服务。

29.Hermann M.Biggs，“The State Board of Health，” New York State Journal of Medicine 21 （January 1921），7；另见 Victor C.Vaughan，“Rural Health Centers as Aids to General Practitioners，”JAMA 76 （April 9，1921），983-985。

30.Milton Terris,"Hermann Biggs'Contribution to the Modern Concept of the Health Center,"Bulletin of the History of Medicine 20 (October 1946),387-412.

31.Edward L.Hunt,"The Health Centres Bill of 1920,"New York State Journal of Medicine 21 (January 1921),2.

32.Greer Williams,"Schools of Public Health—Their Doing and Undoing,"Health and Society 54 (Fall 1976),501-502.

33.Rosenkrantz,Public Health and the State,179,182.

第六章 逃离公司（1900—1930）

1.关于工业医疗在美国的发展，见 Henry B.Selleck，with Alfred H.Whittaker，Occupational Health in America （Detroit：Wayne State University Press，1962），and T.Lyle Hazlett and William W.Hummel，Industrial Medicine in Western Pennsylvania，1850-1950 （Pittsburgh：University of Pittsburgh Press，1957）。

2.关于发展程度的综述，见C.D.Selby，“Studies of the Medical and Surgical Care of Industrial Workers，” Public Health Bulletin，no.99 （1919）；National Industrial Conference Board，Medical Care of Industrial Workers （New York：National Indus-trial Conference Board，1926）；and“Medical and Hospital Service for Industrial Em-ployees，”Monthly Labor Review 24 （January 1927），7-19。

3.Interstate Commerce Commission,Fifteenth Annual Report (Washington,D.C.:U.S.Government Printing Office,1902),58;C.B.Herrick,"The Railway Surgeon and His Work,"Transactions of the Medical Society of the State of New York (1898),214-219.

4.I.M.Rubinow,Social Insurance (New York:Henry Holt,1916),288-289.

5.Pierce Williams,The Purchase of Medical Care Through Fixed Periodic Payments (New York:National Bureau of Economic Research,1932);Jerome Schwartz,"Early History of Prepaid Medical Care Plans," Bulletin of the History of Medicine 39 (Sep-tember-October 1965),450-475.

6.Stuart D.Brandes,American Welfare Capitalism,1880-1920 (Chicago:Universi-ty of Chicago Press,1976).

7.Williams,Purchase of Medical Care,1-23.

8.Schwartz，“Early History of Prepaid Medical Care Plans”，报告称一些工人支持公司的医疗计划，见Brandes，American Welfare Capitalism中更彻底的分析。

9."Contract Practice," JAMA 49 (December 14,1907),2028-2029;Selleck and Whittaker,Occupational Health in America,61;Alice Hamilton,Exploring the Dan-gerous Trades (Boston:Little,Brown,1943),3.

10.National Industrial Conference Board,Health Services in Industry,Report no.34 (New York:National Industrial Conference Board,January 1921),15.

11."Medical and Hospital Service for Industrial Employees," Monthly Labor Re-view 24 (January 1927),7-19;National Industrial Conference Board,Medical Care of Industrial Workers;J.D.Hackett,Health Maintenance in Industry (Chicago:A.W.Shaw,1925).

12.美国医学会的医生们经常反对在职业病的情况中扩大赔偿范围，因为他们将之视为“是在向社会化或国家医疗方向发展”。Carey McCord，“The Present Status of Industrial Medicine，”AMA Bulletin 25 （January 1930），1-21.

13.关于企业家长制的衰落，见Brandes，American Welfare Capitalism。

14.Schwartz,"Early History of Prepaid Medical Care Plans,"455;Note,"Right of Corporation to Practice Medicine,"Yale Law Journal 48 (1938),346-351.

15.Lawrence G.Goldberg and Warren Greenberg,"The Emergence of Physi-cian-Sponsored Health Insurance:A Historical Perspective," in Competition in the Health Sector:Past,Present and Future,ed.Warren Greenberg (Washington,D.C.:Federal Trade Commission,1978),288-321.

16.John Kenneth Galbraith,Economics and the Public Purpose (Boston:Houghton Mifflin,1973),73.

17.Rubinow,Social Insurance,293.

18.Charles Henderson,Industrial Insurance in the United States (Chicago:Univer-sity of Chicago Press,1908),112-127.

19.在这一节中，我借鉴了George Rosen，“Contract or Lodge Practice and Its In-fluence on Medical Attitudes to Health Insurance，”American Journal of Public Health 67 （April 1977），374-378。

20.Anna Kalet，“Voluntary Health Insurance in New York City，”American Labor Legislation Review 6 （June 1916），142-154.关于兄弟会组织和互助会的详细描述，请参见Report of the Health Insurance Commission of Illinois，May 1，1919，118-124。

21.George S.Mathews,"Contract Practice in Rhode Island,"Bulletin of the Ameri-can Academy of Medicine 10 (1909),599.

22.James G.Burrow,Organized Medicine in the Progressive Era:The Move Toward Monopoly (Baltimore:Johns Hopkins University Press,1977),120-122.

23.Horace M.Alleman,"Lodge Practice," Pennsylvania Medical Journal 15 (De-cember 1911),223.

24.Mathews,"Contract Practice in Rhode Island,"602.

25.Ibid.,602-603,604.

26.“Contract Practice，” JAMA 49 （December 14，1907），2028-2029；“Contract Practice，” JAMA 57 （July 8，1911），145-146.1912年，美国医学会司法委员会的一份报告对会社执业给予了同情，但当时委员会的主席是亚历山大·兰伯特（Alex-ander Lambert），他的观点在医学专业中不具代表性。该报告是医疗保险辩论的前奏。见JAMA 60 （June 28，1913），1997-1998。

27.Mathews，“Contract Practice in Rhode Island，”600；Dr.J.K.Weaver，“Discus-sion，” Bulletin of the American Academy of Medicine 10 （1909），630-632.关于医学会对为兄弟会工作的医生的阻挠措施，后来的报告见“Lodge Practice and the Medical Society，” AMA Bulletin 16 （March 15，1923），290-292。强调政策差异的对各州医学会反应的全面考察，见Burrow，Organized Medicine in the Progressive Era，124-132。

28.Irving Howe，World of Our Fathers （New York：Harcourt Brace Jovanovich，1976），188.转引自Rosen，“Contract or Lodge Practice，”375。

29.Henry Keller,"Contract Practice,"The Medical Economist 1 (December 1913),143-149.

30.Williams,Purchase of Medical Care,290-91;Schwartz,"Early History of Pre-paid Medical Care Plans,"452-454.

31.Howe,World of Our Fathers,188.

32.Weaver,"Discussion,"631.

33.引用来自Helen Clapesattle，吀e Doctors Mayo （Minneapolis：University of Min-nesota Press，194），388，392。梅奥诊所的其他细节来自ibid.，339-535。

34.Ibid.;also C.Rufus Rorem,Private Group Clinics (Chicago:University of Chi-cago Press,1931),115-118.

35.Clapesattle,The Doctors Mayo,788;Walker Winslow,The Menninger Story (New York:Doubleday,1956),13-16.

36.American Medical Association,Bureau of Medical Economics,Group Practice (Chicago:American Medical Association,1933),13-17.

37.Rorem,Private Group Clinics,15-18.

38.AMA,Group Practice,14.

39.与拉塞尔·李的私人谈话，加利福尼亚，帕洛阿尔托诊所，1975年。

40.AMA,Group Practice,15.

41.Rorem,Private Group Clinics,13.

42.Clapesattle,The Doctors Mayo,531,534.

43.Michael M.Davis,Jr.,"Organization of Medical Service,"American Labor Leg-islation Review 6 (March 1916),18.

44.Rorem,Private Group Clinics,102.

45."Group Practice—A Menace or a Blessing,"JAMA 76 (February 12,1921),452-453.

46.Rorem,Private Group Clinics,19-20.

47.Veader Newton Leonard，“The Significance of Group Practice，”JAMA 76 （Feb-ruary 12，1921），421-426.Leonard还提到了另外两种类型—封闭式医院的工作人员和诊断小组—但在大多数关于团体执业的讨论中，这些都被排除在外。

48.Rorem,Private Group Clinics,26-31.

49.Rexwald Brown,"Group Medicine in Practice," AMA Bulletin 18 (December 1923),443-448.

50.Edward B.Stevens,The History of the Medical Group Management Association,1926-1976 (Denver:Medical Group Management Association,1976),22.

51.AMA,Group Practice,42.

52.Ibid.,40-42.

53.American Medical Association,Proceedings of the House of Delegates (1934),47.

54.Stephen Marglin,"What Do Bosses Do?The Origins and Functions of Hierar-chy in Capitalist Production,"Review of Radical Political Economics 6 (1974),62.

55.American Medical Association,Bureau of Medical Economics,Economics and the Ethics of Medicine (Chicago:American Medical Association,1935),49-50.

56.Alleman，“Lodge Practice，” 223；Burrow，Organized Medicine in the Progres-sive Era，127亦有引用。

57.AMA,Economics and the Ethics of Medicine,45.

58.Annual Report of the President,1880-81,29.

59.Edward Louis Bauer,Doctors Made in America (Philadelphia:Lippincott,1963),247-249.

60.Bruce Steinwald and Duncan Neuhauser,"The Role of the Proprietary Hospi-tal,"Law and Contemporary Problems 35 (Autumn 1970),818-820;E.H.L.Corwin,The American Hospital (New York:Commonwealth Fund,1946),29.

61.JAMA 92 (March 30,1929),1050.

62.Rosemary Stevens,American Medicine and the Public Interest (New Haven,Conn.:Yale University Press,1971),225-231,238-243.

63.在对临床实验室的讨论中，我完全依据William D.White，Public Health and Private Gain：The Economics of Licensing Clinical Laboratory Personnel （Chicago：Ma-roufa Press，1979）。

64.Ibid.,63.

65.George Unwin,Industrial Organization in the Sixteenth and Seventeenth Centu-ries (Oxford:Clarendon Press,1904),96.

66.Judy Barrett Litoff,American Midwives,1860 to the Present (Westport,Conn.:Greenwood Press,1978),76.

67.Commission on Graduate Medical Education,Graduate Medical Education (Chicago:University of Chicago Press,1940),132-133;Abraham Flexner,Medical Education in the United States and Canada (New York:Carnegie Foundation for the Advancement of Teaching,1910).

68.Stevens,American Medicine and the Public Interest,127-128.

69.Kenneth Arrow,"Uncertainty and the Welfare Economics of Medical Care,"American Economic Review 53 (December 1963),941-969.

70.E.Richard Brown,Rockefeller Medicine Men:Capitalism and Medical Care in America (Berkeley:University of California Press,1979),3-4,119-130,and else-where.

71.Ibid.，117-118.布朗引用了全国制造商协会和全国公民联合会的观点。他显然错把全国制造商协会从未通过的委员会报告作为其官方立场。全国公民联合会对医疗保险的谴责很激烈。见我在下部第一章的讨论。

72.Ibid.,113.

73.Joseph Schumpeter,Capitalism,Socialism and Democracy (New York:Harper&Row,1950),125-126.

下部 为医疗服务而战

第一章 改革的蜃景

1.I.M.Rubinow,Social Insurance (New York:Henry Holt,1916),224-250.

2.Gaston V.Rimlinger,Welfare Policy and Industrialization in Europe,America and Russia (New York:Wiley,1971),Chaps.2 and 3.

3.Reinhard Bendix,Nation-Building and Citizenship (New York:Wiley,1971),80-101.

4.Rimlinger,Welfare Policy and Industrialization;Peter Flora et al.,"On the De-velopment of the Western European Welfare States."(Paper prepared for the Interna-tional Political Science Association,Edinburgh,August 16-21,1976).

5.Rimlinger,Welfare Policy and Industrialization,110-112.

6.Bentley B.Gilbert，British Social Policy，1914-1939 （London：Batsford，1970），15.另见Gilbert的早期著作，The Evolution of National Insurance in Great Britain （London：Michael Joseph，1966），Chaps.6 and 7。

7.Gilbert,Evolution of National Insurance,165-167;Rubinow,Social Insurance,226.

8.Charles R.Henderson,Industrial Insurance in the United States(Chicago:Uni-versity of Chicago Press,1909),112-127;Edgar Sydenstricker,"Existing Agencies for Health Insurance in the United States," in U.S.Department of Labor,Proceedings of the Conference on Social Insurance,1916 (Washington,D.C.:U.S.Government Print-ing Office,1917),430-475.

9.James B.Kennedy,Beneficiary Features of American Trade Unions (Baltimore:Johns Hopkins University Studies in Historical and Political Science,1908);Twen-ty-Third Annual Report of the Commissioner of Labor 1908 (Washington,D.C.:U.S.Government Printing Office,1909),28-30,205-213.

10.Edwin J.Faulkner,Health Insurance (New York:McGraw-Hill,1960),Chap.16;Rubinow,Social Insurance,295-296.

11.John F.Dryden,Addresses and Papers on Life Insurance and Other Subjects (Newark,N.J.:Prudential Press,1909),31-32.

12.Report of the Health Insurance Commission of Illinois，（n.p.：May 1，1919），108 [以 下 简 称 为 “Illinois commission report”]；Ohio Health and Old Age Insurance Commission，Health，Health Insurance，Old Age Pensions （Columbus，Ohio，1919），156 [以下简称为“Ohio commission report”]；Report of the Social Insurance Commission of the State of California，March 1919 （Sacramento：California State Printing office，1919），11.早期的两篇综述，见 Rubinow，Social Insurance，281-298 以及 Syden-stricker，“Existing Agencies for Health Insurance，”esp.431-436。

13.Rubinow,Social Insurance,296,419-420;Marquis James,The Metropolitan Life:A Study in Business Growth (New York:Viking,1947),73-93.

14.关于美国劳工立法协会的背景，见Irwin Yellowitz，Labor and the Progressive Movement in New York State，1897-1916 （Ithaca，N.Y.：Cornell University Press，1965），55-59；John R.Commons and A.J.Altmeyer，“The Health Insurance Move-ment in the United States，”in Ohio commission report，291-292；以及Roy Lubove，The Struggle for Social Security，1900-1935 （Cambridge：Harvard University Press，1970）。

15.关于该协会的参照法案，见American Labor Legislation Review 6 （June 1916），239-268。

16.Yellowitz,Labor and the Progressive Movement,85.

17.Illinois commission report,15-17;Rubinow,Social Insurance,214.

18.Illinois commission report,15,18.

19.Ibid.，20-22.纽约慈善机构协会发现，在五千个慈善救助案例的样本中，有四分之三是由疾病引起的。见Hace Sorel Tishler，Self-Reliance and Social Security，1870-1917 （Port Washington，N.Y.：Kennikat Press，1971），164。

20.Rubinow，Social Insurance，298.关于鲁比诺的一般政治观点和职业生涯，见J.Lee Kreader，“Isaac Max Rubinow：Pioneering Specialist in Social Insurance，”Social Service Review 50 （September 1976），402-425。

21.Irving Fisher,"The Need for Health Insurance," American Labor Legislation Review 7 (March 1917),23.

22.B.S.Warren and Edgar Sydenstricker,"Health Insurance:Its Relation to Public Health,"Public Health Bulletin,no.76 (March 1916),6.

23.Ibid.,54.

24.I,M.Rubinow,"Social Insurance" (Chicago:American Medical Association,1916),24.

25.Ohio commission report,136.

26.Ronald L.Numbers，Almost Persuaded：American Physicians and Compulsory Health Insurance （Baltimore：Johns Hopkins University Press，1978） and Tishler，Self-Reliance and Social Security，167-170.我的讨论从这两项研究获益匪浅。

27.Numbers,Almost Persuaded,34.

28.Warren and Sydenstricker,"Health Insurance";"Report of the Standing Com-mittee Adopted by the Conference of State and Territorial Health Authorities with the United States Public Health Service,Washington,D.C.,May 13,1916,"Public Health Reports 31 (July 21,1916),1919-1925;Alexander Lambert,"Organization of Medical Benefits Under the Proposed Sickness (Health) Insurance System," in U.S.Depart-ment of Labor,Proceedings of the Conference on Social Insurance,1916,651-653.

29.Michael M.Davis,Jr.,to John B.Andrews,July 21,1915,in Papers of the Amer-ican Association for Labor Legislation,1905-1945 (Glen Rock,N.J:Microfilm Corpo-ration of America,1973),reel 14.

30.Lambert,"Organization of Medical Benefits,"655-659.

31.Numbers,Almost Persuaded,50-51.

32.American Labor Legislation Review 7 (March 1917),51-65;Numbers,Almost Persuaded,84.

33.U.S.Congress,House Committee on Labor,Hearings Before the Committee on H.J.Resolution 159...April 6 and 11,1916,64th Cong.,1st sess.,36-45,122-189.

34.Marc Karson,American Labor Unions and Politics,1900-1918 (Carbondale,Ill.:Southern Illinois University Press,1958).

35.Selig Perlman,A Theory of the Labor Movement (New York:Macmillan,1928),162.

36.Nathan Fine,Labor and Farmer Parties in the United States,1828-1928 (New York:Rand School of Social Science,1928),129.

37.Bernard Mandel,Samuel Gompers (Yellow Springs,Oh.:Antioch Press,1963),32.

38.Ibid.，183；另见Samuel Gompers，“Trade Union Health Insurance，”American Federationist 23 （November 1916），1072-1074；Philip Taft，The A.F.of L.in the Time of Gompers （New York：Harper&Row，1957），364-365。

39.Commons and Altmeyer，“Health Insurance Movement，”300.龚帕斯的反对意见并非不可克服。纽约州联合会支持一项法案，该法案将在强制体系下提供低现金福利，从而为兄弟会和工会计划提供额外的现金福利留下空间。此外，德国的保险制度也已经刺激了工会的发展，因为它为工人提供了选举代表的机会。

40.National Association of Manufacturers,Proceedings of the 21st Annual Conven-tion,May 15-17,1916,33-38;idem,Proceedings of the 22nd Annual Convention,May 14-16,1917,20-21;Frank F.Dresser,"Suggestions Regarding Social Insurance."(An Address Before the Conference on Social Insurance,Washington,D.C.,December 4-9,1916,NAM Pamphlet 46).

41.National Industrial Conference Board,"Sickness Insurance or Sickness Preven-tion?" Research Report no.6 (Boston:National Industrial Conference Board,1918),and idem,"Is Compulsory Health Insurance Desirable?"Special Report no.4 (Boston:National Industrial Conference Board,1919).

42.关于全国公民联合会的背景，见James Weinstein，The Corporate Ideal in the Liberal State：1900-1918 （Boston：Beacon Press，1968）。

43.Karson,American Labor Unions and Politics;Yellowitz,Labor and the Progres-sive Movement;Robert Wiebe,Businessmen and Reform (Cambridge:Harvard Univer-sity Press,1962),158-167.

44.Tishler,Self-Reliance and Social Security,179-189.

45.Ibid.；对于一系列意见，见“If Not Compulsory Insurance，What” National Civic Federation Review 4 （June 5，1919）。

46.James,Metropolitan Life,171-172.

47.Numbers,Almost Persuaded,78;F.L.Hoffman,Facts and Fallacies of Compul-sory Insurance (Newark,N.J.:Prudential Press,1917).

48.Lee K.Frankel,"Some Fundamental Considerations in Health Insurance," in U.S.Department of Labor,Proceedings of the Conference on Social Insurance 1916,598-605.

49.Numbers,Almost Persuaded,67.

50.Ibid.,73.

51.Ibid.,75-77.

52.League for the Conservation of Public Health,"It Shall Not Pass," (n.d.,n.p.) and letters to doctors,October 8,1918,Ray Lyman Wilbur papers,Stanford Universi-ty,Stanford,Calif.

53.Arthur Viseltear,"Compulsory Health Insurance in California,1915-1918,"Journal of the History of Medicine and the Allied Sciences 24 (April 1969),151-182;Numbers,Almost Persuaded,79-81.

54.Lubove,The Struggle for Social Security,83-84.

55.Illinois commission report,209.

56.I.M.Rubinow,"Public and Private Interests in Social Insurance," American Labor Legislation Review 21 (June 1931),181-191.

57.甚至Lubove在《为社会保障而战》中的其他方面都令人钦佩的叙述也避开了问题的复杂性，他忽视了美国医学会早期对医疗保险的支持，并将医生的反应视为客观利益的自动表达。

58.Gilbert,Evolution of National Insurance,425-428.

59.Rimlinger,Welfare Policy and Industrialization,112-122.

60.Gilbert,Evolution of National Insurance,356-440.

61.Chester Rowell to Ray Lyman Wilbur,October 7,1918.Wilbur Papers.

62.据统计数字，从1916年到1919年，威斯康星州征税医生的平均收入增长了41%。见Almost Persuaded，113。

63.Lubove，The Struggle for Social Security，45-51；另见Lawrence M.Friedman and Jack Ladinsky，“Social Change and the Law of Industrial Accidents，” Columbia Law Review 67 （January 1967），50-82。

64.I.S.Falk,Security Against Sickness (Garden City,N.Y.:Doubleday,Doran,1936),14-16.(https://www.daowen.com)

65.Michael M.Davis,Jr.,preface to Harry A.Millis,Sickness and Insurance (Chica-go:University of Chicago Press,1937),v.

66.Michael M.Davis,Jr.,"The American Approach to Health Insurance,"Milbank Memorial Fund Quarterly 12 (July 1934),214.

67.Milton Friedman and Simon Kuznets,Income from Independent Professional Practice (New York:National Bureau of Economic Research,1945).

68.Ohio insurance commission,116.

69.I.S.Falk，C.Rufus Rorem，and Martha D.Ring，吀e Cost of Medical Care （Chicago：University of Chicago Press，1933），89.这只是对私人支出的估计；如果把用于医院护理的税收计算在内，社会支出中用于医院的比例为23%（第19页）。

70.Davis,"American Approach,"211.

71.Committee on the Costs of Medical Care,Medical Care for the American People (Chicago:University of Chicago Press,1932),19.

72.Davis,"American Approach,"214-215.

73.Sheila M.Rothman,Woman's Proper Place (New York:Basic Books,1978),136-152.

74.Harry H.Moore,American Medicine and the People's Health (New York:Ap-pleton,1927),21.

75.Paul Kellogg to Edward Filene,November 7,1927.Wilbur papers.

76.CCMC，Medical Care for the American People，Chap.1.调查结果的总体摘要见Falk，Rorem，and Ring，Cost of Medical Care。

77.CCMC,Medical Care for the American People,32-36.

78.Roger I.Lee,Lewis Webster Jones,and Barbara Jones,The Fundamentals of Good Medical Care (Chicago:University of Chicago Press,1933),12.

79.Ibid.

80.CCMC,Medical Care for the American People,7.

81.Ibid.,41.

82."Introduction,"in Falk,Rorem,and Ring,Cost of Medical Care,vi-vii.

83.CCMC,Medical Care for the American People,61,128-130.

84.Ibid.,94.

85.Ibid.,68.

86.Ibid.,130-132,189-201.

87.Ibid.,152-183.

88."The Committee on the Costs of Medical Care,"JAMA 99 (December 3,1932),1950-1951.

89.New York Times,November 30,1932.

90.Flora和他的同事对12个主要欧洲国家的强制或补贴自愿保险计划的施行顺序进行了平均，发现工业意外保险排名1.7；疾病保险2.2；养老保险2.7；失业保险3.5。见Flora et al.，“On the Development of the Western European Welfare States，”22。

91.Paul H.Douglas,Social Security in the United States (New York:McGraw-Hill,1936),70.

92.Edwin Witte，The Development of the Social Security Act （Madison，Wis.：Uni-versity of Wisconsin Press，1962），174-175.关于威特，见Theron F.Schlabach，Ed-win Witte：Cautious Reformer （Madison，Wis.：State Historical Society of Wisconsin，1969）。

93.Abraham Epstein,"Social Security—Fiction or Fact?" The American Mercury 33 (October 1934),129-138.

94.Witte,Development of the Social Security Act,175-180;Daniel S.Hirshfield,The Lost Reform (Cambridge:Harvard University Press,1970),44-52.

95.Committee on Economic Security,Report to the President (Washington,D.C.:U.S.Government Printing Office,1935).

96.“Report of the Special Reference Committee，”JAMA 104 （March 2，1935），751-752.这其实根本就不是让步。

97.Arthur J.Altmeyer,The Formative Years of Social Security (Madison,Wis.:Uni-versity of Wisconsin Press,1968),57-58n;Witte,Development of the Social Security Act,185ff,205-210;Hirshfield,Lost Reform,55-60.

98.Douglas,Social Security,100-101.

99.G.St.J.Perrot,Edgar Sydenstricker,and Selwyn D.Collins,"Medical Care During the Depression,"Milbank Memorial Fund Quarterly 12 (April 1934),99-114.

100.New York Times,June 12,1938.

101.Paul A.Dodd,Economic Aspects of Medical Services (Washington,D.C.:Graphic Arts Press,1939),209;Simon Kuznets and Milton Friedman,"Income from Independent Practice,1929-1936," National Bureau of Economic Research Bulletin (February 5,1939),8;George D.Wolf,The Physician's Business (Philadelphia:Lip-pincott,1938),112.

102.New York State Legislative Commission on Medical Care，Medical Care for the People of New York State （n.p.：February15，1946），171-172；Franz Goldmann，Public Medical Care （New York：Columbia University Press，1945）.尽管联邦政府没有为老年援助项下的医疗保健拨款，但其对现金补贴的贡献让各州原本用于医疗保健的资金可以用于别处。华盛顿州在1941年规定，65岁以上的人有权获得“由公共费用承担的或多或少完整的医疗服务”（ibid.，74）。

103.Samuel Lubell and Walter Everett,"Rehearsal for State Medicine," Saturday Evening Post,December 17,1938,23ff.

104.Morris Fishbein,History of the American Medical Association (Philadelphia:Saunders,1947),407-408.

105.Mary Ross,"California Weighs Health Insurance," Survey Graphic 24 (May 1935),213ff.

106.George A.Shipman,Robert J.Lampman and S.Frank Miyamoto,Medical Ser-vice Corporations in the State of Washington (Cambridge:Harvard University Press,1962),22-23.

107.Walter Bierring,"The Family Doctor and the Changing Order," JAMA 102 (June 16,1934),1997.

108.Friedman and Kuznets,Incomes from Independent Professional Practice,12-20.

109.Hirshfield,The Lost Reform,76-78.

110.Oliver Garceau,The Political Life of the American Medical Association (Cam-bridge:Harvard University Press,1941),132.

111.Ibid.,77

112.George Gallup,"Most Doctors Back Health Insurance,"New York Times,June 15,1938;Garceau,Political Life,133-134.

113.Hirshfeld,The Lost Reform,128-130;Garceau,Political Life,147-152.

114.引自James Rorty，American Medicine Mobilizes （New York：Norton，1939），93-94；另见John P.Peters，“Medicine and the Public，”New England Journal of Medicine 220 （March 23，1939），504-510。

115."The American Foundation Proposals for Medical Care,"JAMA 109 (October 16,1937),1280-1281.

116.Hirshfield,The Lost Reform,102-105.

117."A National Health Program:Report of the Technical Committee on Medical Care,"in Interdepartmental Committee to Coordinate Health and Welfare Activities,Proceedings of the National Health Conference,July 18,19,20,1938,Washington,D.C.(Washington,D.C.:U.S.Government Printing Office,1938),29-63.

118.Altmeyer,Formative Years,96.

119.“Procedings of the Special Session，” JAMA 111 （September 24，1938），1191-1217；Morris Fishbein，“American Medicine and the National Health Plan，”New Eng-land journal of Medicine 220 （March 23，1939），495-504.菲什拜因调侃了国家卫生计划。

120.Arthur J.Viseltear,"Emergence of the Medical Care Section of the American Public Health Association,1926-48,"American Journal of Public Health 63 (Novem-ber 1973),992.

121.Altmeyer,Formative Years,96.

122.Ibid.,115.

123.Robert F.Wagner,"The National Health Bill,"American Labor Legislation Re-view 29 (1939),13-44.

124.Altmeyer,Formative Years,126-127.

125.William Leuchtenberg,Franklin D.Roosevelt and the New Deal,1932-1940 (New York:Harper&Row,1963),88.

126.Hirshfield,The Lost Reform,passim.

127.在对公众舆论的讨论中，我依据E.Schiltz，Public Attitudes Toward Social Security 1935-1965 （Washington，D.C.：U.S.Government Printing Office，1970），123-150。

128.John Blum,From the Morgenthau Diaries:Years of War,194-1945 (Boston:Houghton Mifflin,1967),72.

129.Altmeyer,Formative Years,261.

130.关于该法案的背景，见Monty M.Poen，Harry S.Truman Versus the Medical Lobby （Columbia，Mo.：University of Missouri Press，1979），31-36。以下讨论的大部分内容受惠于Poen的叙述。

131.Ibid.,42-43

132."A National Health Program:Message from the President," Social Security Bulletin (December 1945),7.

133.Ibid.,8.

134.Ibid.,1.

135.A.J.Altmeyer,"How Can We Assure Adequate Health Service for All the Peo-ple?"Social Security Bulletin (December 1945),15-16.

136.Poen,Truman Versus the Medical Lobby,85-86.

137.Schiltz,Public Attitudes Toward Social Security,134.

138.Foote,Cone,and Belding,Survey of Public Relations of the California Medical Profession (n.p.,1944),4-5.

139.New York State Legislative Commission,Medical Care for the People of New York State,26-28.

140.Foote,Cone,and Belding,Survey of Public Relations;Schiltz,Public Attitudes Toward Social Security,136-139.

141.Richard Harris,A Sacred Trust (New York:New American Library,1966),31-33.

142.U.S.Senate,National Health Program,Hearings Before the Committee on Ed-ucation and Labor,77th Cong.,2nd sess.,pt.1,April 2-16,1946,47ff.

143.Poen,Truman Versus the Medical Lobby,75-80,90.

144.Ibid.,96-97.

145.Ibid.,102-106.

146.National Health Assembly,America's Health:A Report to the Nation (New York:Harper and Brothers,1949).

147.Harris,Sacred Trust,44-46.

148.Schiltz,Public Attitudes Toward Social Security,134.

149.Poen,Truman Versus the Medical Lobby,118-122.

150.Altmeyer,Formative Years,261-262.

151.Ibid.,185-186.

152.Poen,Truman Versus the Medical Lobby,181-182.

153.Godfrey Hodgson,America in Our Time (New York:Doubleday,1977),77.

第二章 妥协的成功

1.William C.L.Hsiao and Beth Stevens，“Cooptation Versus Isolation：Health Insurance Organizations and Their Relations with Physicians，” （unpublished paper，Harvard University School of Public Health，July 15，1980）发展出了赔偿计划和服务权益计划代表不同的风险处理方法的观点。

2.Marquis James,The Metropolitan Life:A Study in Business Growth (New York:Viking,1947),262-264;Report of the Health Insurance Commission of Illinois (n.p.:May l,1919),135-140;Edwin J.Faulkner,Health Insurance (New York:McGraw-Hill,1960),Chap.16.

3.Pierce Williams,The Purchase of Medical Care Through Fixed Periodic Payment (New York:National Bureau of Economic Research,1932),258-260.

4.Committee on the Costs of Medical Care,Medical Care for the American People (Chicago:University of Chicago Press,1932),91-92.

5.传统的叙述，见C.Rufus Rorem，Blue Cross Hospital Service Plans （Chicago：Hospital Service Plan Commission，1944），7；关于私人促销，见Michael M.Davis and C.Rufus Rorem，吀e Crisis in Hospital Finance （Chicago：University of Chicago Press，1932），211-213；另见Louis S.Reed，Blue Cross and Medical Service Plans （Washington，D.C.：Federal Security Agency，1949），9-10。

6."A Statistical Analysis of 2717 Hospitals,"Bulletin of the American Hospital As-sociation 4 (July 1930),68.

7.Davis and Rorem,Crisis in Hospital Finance,5.

8.Ibid.,3.

9.Ibid.,12.

10.Rorem,Blue Cross Hospital Service Plans,7,12-13.

11.Reed,Blue Cross and Medical Service Plans,13-14,54-56.

12.Odin W.Anderson,Blue Cross Since 1929:Accountability and the Public Trust (Cambridge,Mass.:Ballinger,1975),42.

13.Reed,Blue Cross and Medical Service Plans,11-12,54-58.

14.Rorem,Blue Cross Hospital Service Plans,11.

15.通过维持那些本来会因竞争而破产的医院，社区计划可以说是保留了更多的替代医疗场所。但人们可能没有意识到他们正在为这样的做法所需的花费付钱。

16.C.Rufus Rorem,"Group Hospitalization Plans Forge Ahead," Hospitals 10 (April 1936),62-66;"Group Hospitalization Plans Protect One Million Persons,"Hospitals 11 (July 1937),120-122.

17.Anderson,Blue Cross Since 1929,40.

18.Duncan M.MacIntyre，Voluntary Health Insurance and Rate Making （Ithaca，N.Y.：Cornell University Press，1962），124-125；C.A.Kulp，Casualty Insurance （New York：Ronald Press，1956）；U.S.Senate，Committee on Labor and Public Welfare，Health Insurance Plans in the United States，Report no.359，pt.2，82d Cong.，1st sess.，1951（以下简称为“1951 Senate Report”），99.

19.Herman N.Somers and Anne R.Somers,Doctors,Patients and Health Insur-ance (Washington,D.C.:The Brookings Institution,1961),548.

20.JAMA 104 (May 4,1935),1614.

21.JAMA 111 (September 24,1938),1216.

22.Davis and Rorem,Crisis in Hospital Finance,90-96.

23.E.M.Dunstan and Jo C.Alexander,"Group Hospitalization Plan:Survey of Local Organized Medical Opinion on the Baylor University Hospital," Hospitals 10 (August 1936),75-81.

24.JAMA 102 （June 30，1934），2200-2201.这是下文出现的十项原则的引文出处。

25.在1935年的美国医学会代表大会上，措辞被修改为：“无论医疗服务费用以何种方式分配，都应该由病人根据其收入状况，以双方满意的方式支付。”JAMA 104 （June 29，1935），2364.

26.Davis and Rorem,Crisis in Hospital Finance,202-203.

27.George A.Shipman et al.,Medical Service Corporations in the State of Washing-ton (Cambridge:Harvard University Press,1962).

28.Mary Ross,"The Case of the Ross-Loos Clinic,"Survey Graphic 24 (June 1935),300ff;Arnold I.Kisch and Arthur J.Viseltear,The Ross-Loos Medical Group,U.S.Public Health Service,Medical Care Administration Study no.3 (1967).

29.Paul de Kruif,Kaiser Wakes the Doctors (New York:Harcourt Brace,1943),20-35.

30.Davis and Rorem,Crisis in Hospital Finance,205-206.

31."How Prepayment Got Its Start,"Group Practice 22 (December 1973),17-19.

32.Jerome Schwartz,"Early History of Prepaid Medical Care Plans,"Bulletin of the History of Medicine 39 (September-October 1965),470-475,and idem,"Prepayment Clinics of the Mesabi Iron Range:1904-1964,"Journal of the History of Medicine and the Allied Sciences 22 (April 1967),139-151.

33.Michael Shadid,"Rural Health Projects in Action—II,"American Cooperation,1946 (Washington,D.C:American Institute of Cooperation,1947),429.

34.Michael Shadid,A Doctor for the People (New York:The Vanguard Press,1939).

35.Ben Swigart,"Rural Health Projects in Action—I," American Cooperation,1946,423-428;Eugene Butler,"Cooperatives and Rural Health:II.What Texas Has Done,"American Cooperation,1947,420-427.

36.Franz Goldmann,Voluntary Medical Care Insurance in the United States (New York:Columbia University Press,1948),130,135.

37.Goldmann，Voluntary Medical Care Insurance，65-66.产业工会联合会次年建议，作为对全民医疗保险的“刺激”，产业工会联合会的工会协助在社区成立医疗合作社。

38.Shadid,"Rural Health Projects in Action,"432.

39.Michael Shadid,"Cooperative Versus Competitive Medicine,"American Coop-eration,1940,83-88.

40.Ross,"Case of the Ross-Loos Clinic";Andrew and Hannah Biemiller,"Medical Rift in Milwaukee," Survey Graphic 27 (August 1938),418-420;Waldeman Kaemp-ffert,"Group Practice Fight Growing More Bitter,"New York Times,August 7,1938;Thomas N.Bonner,Medicine in Chicago (Madison,Wis.:American Historical Re-search Center,1957),217-218;James Rorty,American Medicine Mobilizes (New York:Norton,1939),135ff.

41.American Medical Association v.United States 110 F 2d 703;Rorty,American Medical Mobilizes,286.

42.110 F 2d 703.

43.Washington Post，December 21，1938（强调为我所加）。

44.American Medical Association v.United States 317 U.S.519 (1943).

45.Horace R.Hansen,"Group Health Plans:A Twenty-Year Legal Review," Min-nesota Law Review 42 (March 1958),527-548.

46.JAMA 111 (July 2,1938),59.

47.Ibid.,119 (June 20,1942),727-728.

48.Anderson,Blue Cross Since 1929,58n.

49.Reed,Blue Cross and Medical Service Plans,137-141;Joseph W.Garbarino,Health Plans and Collective Bargaining (Berkeley:University of California Press,1960),89-106,

50.Garbarino,Health Plans and Collective Bargaining,106-111.

51.Anderson,Blue Cross Since 1929,45;Nathan Sinai,Odin W.Anderson,and Melvin L.Dollar,Health Insurance in the United States (New York:Commonwealth Fund,1946),73,84-94

52.Sinai,Anderson,and Dollar,Health Insurance in the United States,64-65.

53.Reed,Blue Cross and Medical Service Plans,81-91.

54.Ibid.,69-71;Cone,Foote,and Belding,"Survey of Public Relations of the Cali-fornia Medical Association,"81.New York Legislative Commission on Medical Care,Medical Care for the People of New York State (n.p.:February 15,1946),223.

55.Ibid.,81-82.

56.Daniel Hirshfield,The Lost Reform (Cambridge:Harvard University Press,1970),97.

57.Leon Applebaum,"The Development of Voluntary Health Insurance in the United States,"Journal of Risk and Insurance (September 1961),15-23;John T.Dun-lop,"Appraisal of the Wage Stabilization Policies,"U.S.Department of Labor,Bulle-tin no.1009,166-167.

58.Raymond Munts,Bargaining for Health (Madison,Wis.:University of Wiscon-sin Press,1960),7-12.

59.Ibid.,9-10;Garbarino,Health Plans and Collective Bargaining,19.

60.关于《塔夫脱-哈特莱法案》，参见Munts，Bargaining for Health，10-12，以及Arthur F.McClure，The Truman Administration and the Problems of Postwar Labor，1945-1948 （Rutherford，N.J.：Fairleigh Dickinson Press，1969），162-184。

61.H.M.Douty,"Post-war Wage Bargaining in the United States," in Labor and Trade Unionism,ed.Walter Galenson and Seymour Martin Lipset (New York:Wiley,1960),192-202.

62.Garbarino,Health Plans and Collective Bargaining,19-20.

63.Odin W.Anderson and Jacob J.Feldman,Family Medical Costs and Voluntary Health Insurance:A Nationwide Survey (New York:McGraw-Hill,1956),11.

64.1951 Senate Report,98-99.

65.Ibid.,122.

66.Munts,Bargaining for Health,104.

67.Garbarino,Health Plans and Collective Bargaining,280-282.

68.以下的分析依赖于Janet E.Ploss，“A History of the Medical Care Program of the United Mine Workers of America Welfare and Retirement Fund”（Master’s thesis，Johns Hopkins School of Hygiene and Public Health，1980）。我非常感谢Ploss女士允许我借鉴她的出色研究。

69.见Derek C.Bok and John T.Dunlop，Labor and the American Community （New York：Simon and Schuster，1970）。

70.Ploss,"History of the Medical Care Program,"Chap.1.

71.U.S.Department of the Interior,A Medical Survey of the Bituminous-Coal In-dustry (Washington,D.C.:U.S.Government Printing Office,1947),75-77,111,123,137-164.

72.Ploss,"History of the Medical Care Program," Chap.2;Leslie Falk,"Group Health Plans in Coal Mining Communities,"Journal of Health and Human Behavior 4 (Spring 1963),4-13.

73.Munts，Bargaining for Health，99；另见idem，61-63，以及Garbarino，Health Plans and Collective Bargaining，182。

74.Munts,Bargaining for Health,21.

75.Garbarino，Health Plans and Collective Bargaining，149-157；另 见 Wallace Croatman，“Are Labor’s Health Centers a Threat to Doctors？”Medical Economics 31 （October 1954），109-118。

76.Goldmann,Voluntary Medical Care Insurance,150.

77.Angus McDonald,"Health on the Farm," The New Republic 116 (March 3,1947),32-33.

78.Jerry Voorhis，American Cooperatives （New York：Harpers and Brothers，1961），32；Somers and Somers，Doctors，Patients and Health Insurance，348-349.另见Helen L.Johnston，“Rural Health Cooperatives，”Public Health Bulletin no.308 （1950）。

79.William A.MacColl，“Reflections on the Birth of Group Health，”Group Health Cooperative of Puget Sound，February 1972，4.另 见 idem，Group Practice and Pre-payment of Medical Care （Washington，D.C.：Public Affairs Press，1966），36-42。

80.关于凯泽的早期历史，见de Kruif，Kaiser Wakes the Doctors，passim；Greer Williams，Kaiser-Permanente Health Plan：Why It Works （Oakland，Calif.：Henry J.Kaiser Foundation，1971），4-6；Waldemar Nielsen，The Big Foundations （New York：Columbia University Press，1973），245-249；E.W.Saward et al.，“Documentation of Twenty Years of Operation and Growth of a Prepaid Group Practice Plan，” Medical Care 6 （May-June 1968），231-244。

81.关于HIP，见George Baehr，A Report of the First Ten Years （New York：HIP，1957）；Louis L.Feldman，Organization of a Medical Group Practice Prepayment Pro-gram in New York City （New York：HIP，1953） and idem，“Legislation and Prepay-ment for Group Practice，” Bulletin of the New York Academy of Medicine 47 （April 1971），411-422.。

82.“The Patient’s Dilemma，”San Francisco Chronicle，February 22，1949，重印于U.S.Senate，National Health Program，1949，Hearing Before a Subcommittee of the Committee on Labor and Public Welfare，pt.1，May 23-June 2，1949，81 Cong.，1st sess.，271-276；Garbarino，Health Plans and Collective Bargaining，125-127。

83.Garbarino,Health Plans and Collective Bargaining,205-223.

84.Kenneth P.Andrews,"How They're Fighting the Kaiser Plan," Medical Eco-nomics 31 (September 1954),126-131.

85.Group Health Cooperative of Puget Sound v.King County Medical Society，39 Wash.2d 586，237 Pac 2d 737 （1951）；另见Claron Oakley，“Closed Panel Plans are Hard to Beat in Court，”Medical Economics 32 （May 1955），103-107。

86.Claron Oakley,"They Met the Challenge of Panel Medicine,"Medical Econom-ics 32 (February 1955),122-130.

87.Garbarino,Health Plans and Collective Bargaining,191-196.

88.Commission on Medical Care Plans,Report,pt.1.,JAMA January (17,1959),34-42,63.

89.然而，合作社的集体参保者（截至1973年约占成员的60%）作为成员没有投票权；他们在定期谈判中由他们的议价代理人代表。该计划的双重结构起源于1945年，当时合作社购买了医疗安全诊所（Medical Security Clinic），该诊所的资产中包含几个工业合同。相关讨论见“Who Should Run Group Health？” View （Group Health Cooperative），January-February 1973，4-6。另见Jerome L.Schwartz，“Participation of Consumers in Prepaid Health Plans，”Journal of Health and Human Behavior 5 （Summer and Fall 1964），74-84。

90.1951 Senate Report，80-81；Odin W.Anderson，Patricia Collette，and Jacob J.Feldman，Changes in Family Medical Expenditures and Voluntary Health Insurance：A Five-Year Resurvey （Cambridge：Harvard University Press，1963），8-9.1953年至1958年期间，商业保险公司、蓝十字和独立计划的相对地位基本保持不变。然而，蓝盾的市场份额有了显著的增加。

91.1951 Senate Report,74-79,99-106.

92.MacIntyre，Voluntary Health Insurance and Rate Making 58.这些数据是1959年的数据，但更早时候的模式是一样的。见1951 Senate Report，110-111，and Somers and Somers，Doctors，Patients and Health Insurance，300，326-327。

93.MacIntyre,Voluntary Health Insurance and Rate Making,26-49;Somers and Somers,Doctors,Patients and Health Insurance,309-311.

94.Ibid.,155-161.

95.Garbarino,Health Plans and Collective Bargaining,228.

96.Somers and Somers,Doctors,Patients and Health Insurance,304.

97.Ibid.，261-262，引用库尔普的说法.

98.其他因素如人均收入，与蓝十字的发展呈正相关。但正如里德所指出的，在太平洋各州，人均收入很高，医院却并不是“严格无偿的”，许多医院最近才从私有状态转换过来。蓝十字在那里取得的进展相对缓慢。见Reed，Blue Cross and Medical Service Plans，28-30。

99.Somers and Somers,Doctors,Patients and Health Insurance,300.

100.Anderson,Collette,and Feldman,Changes in Family Medical Expenditures,4-6,171.

101.Garbarino,Health Plans and Collective Bargaining,22.

第三章 自由年代开明岁月

1.U.S.Public Health Service,Office of Research,Statistics and Technology,Health:United States 1981 (Hyattsville,Md.:U.S.Department of Health and Human Services,1981),263;Maryland Y.Pennell and David B.Hoover,Health Manpower Source Book 21:Allied Health Manpower Supply and Requirements:1950-1980 (Bethesda,Md.:U.S.Department of Health,Education and Welfare,1970),4.

2."Report of the Medical Advisory Committee," in Vannevar Bush,Science:The Endless Frontier (1945;reprint ed.,Washington,D.C.:National Science Foundation,1960),49.

3.Godfrey Hodgson,America in Our Time (New York:Doubleday,1976),19.

4.例如见Harry Stack Sullivan，“Remobilization for Enduring Peace and Social Pro-gress，”Psychiatry 10 （August 1947），239-252；批判性的评论见Christopher Lasch，Haven in a Heartless World：吀e Family Besieged （New York：Basic Books，1977），97-99。

5.A.Hunter Dupree,"Central Scientific Organization in the United States Govern-ment,"Minerva 1 (Summer 1963),453-469.

6.Richard H.Shryock，American Medical Research （New York：Commonwealth Fund 1947），991-998.以下段落经常借鉴该书。

7.转引自ibid.，135-136。

8.关于农业部的科学作用，见Dupree，“Central Scientific Organization”；在环境毒理学方面，见James Whorton，Before Silent Spring：Pesticides and Public Health in Pre-DDT America （Princeton，N.J.：Princeton University Press，1974）；关于抗生素，见 Selman A.Waksman，“The Microbiology of the Soil and the Antibiotics，” in The Impact of the Antibiotics on Medicine and Society，ed.Iago Galdston （New York：International Universities Press，1958），3-7。

9.Stephen Strickland，Politics，Science and Dread Disease：A Short History of United States Medical Research Policy （Cambridge：Harvard University Press，1972），1-14.关于那一段的基本历史，见Ralph C.Williams，The United States Public Health Ser-vice，1798-1950 （Richmond，Va.：Whittet&Shepperson，1951）。

10.Shryock，American Medical Research，277.关于国家癌症研究所的历史，见[Devra M.Breslow]，A History of Cancer Control in the United States，1996-1971，II，A History of Programmatic Developments in Cancer Control，U.S.Department of Health，Education and Welfare，National Cancer Institute，Publication no.（NIH） 79-1518；and Richard A.Rettig，Cancer Crusade：The Story of the National Cancer Act of 1971 （Princeton，N.J.：Princeton University Press，1977）。

11.A.N.Richards,"The Impact of the War on Medicine," Science 103 (May 10,1946),578.

12.Bush，Science：The Endless Frontier，6，10-12，31-40.关于该报告的背景，见J.M.England，“Dr.Bush Writes a Report：‘Science—the Endless Frontier，’”Science 191 （January 9，1976），41-47；更一般性的讨论见Daniel S.Greenberg，The Politics of Pure Science （New York：New American Library，1967）。

13.关于公共卫生局的活动和战后发展的总结，见 Congressional Quarterly Ser-vice，Congress and the Nation，1945-64：A Review of Government and Politics in the Postwar Years （Washington，D.C.：Congressional Quarterly Service，1965），1126-1133；以及Williams，United States Public Health Service。该预算数据来自Strick-land，Politics，Science and Dread Disease，29。

14.关于拉斯克游说团，见 Strickland，Politics，Science and Dread Disease，32-54，以及Elizabeth Brenner Drew，“The Health Syndicate：Washington’s Noble Conspira-tors，”Atlantic Monthly 220 （December 1967），75-82。

15.Kenneth M.Endicott and Ernest M.Allen，“The Growth of Medical Research 194-1953 and the Role of the Public Health Service Research Grants，” Science 118 （September 25，1953），337.另 见 Thomas B.Turner，“The Medical Schools Twenty Years After-wards：Impact of the Extramural Research Support of the National Insti-tutes of Health，”Journal of Medical Education 42 （February 1967），109-118。

16.Endicott and Allen,"Growth of Medical Research,"341.

17.Morris Janowitz,The Professional Soldier (New York:Free Press,1960).

18.William Menninger,Psychiatry in a Troubled World:Yesterday's War and To-day's Challenge (New York:Macmillan,1948).

19.William Menninger，Psychiatry：Its Evolution and Present Status （Ithaca，N.Y.：Cornell University Press，1948），2.关于精神病学的早期发展，见Nathan G.Hale，Jr.，Freud and the Americans （New York：Oxford University Press，1971）。

20.Albert Deutsch，The Shame of the States （New York：Harcourt Brace，1948），138-139.另 见 idem，The Mentally Ill in America （New York：Columbia University Press，1949），448-449。

21.关于此项立法的背景，见Jeanne L.Brand，“The National Mental Health Act of 1946：A Retrospect，”Bulletin of the History of Medicine 39 （May-June 1965），231-244。关于NIMH的崛起，见Robert H.Connery et al，The Politics of Mental Health （New York：Columbia University Press，1968）。

22.Richard Carter，Breakthrough：The Saga of Jonas Salk （New York：Trident Press，1966），1.另见David Sills，The Volunteers （Glencoe，Ill.：Free Press，1957），esp.176-199，and John R.Paul，A History of Poliomyelitis （New Haven，Conn.：Yale University Press，1971）。

23.预算表见Congressional Quarterly Service，Congress and the Nation，1132。关于国会的支持，见Strickland，Politics，Science and Dread Disease，75-183；美国国家卫生研究院院长在其黄金时代的总体回顾，见James A.Shannon，“The Advance-ment of Medical Research：A Twenty Year View of the Role of the National Institutes of Health，”Journal of Medical Education 42 （February 1967），97-108。

24.Strickland,Politics,Science and Dread Disease,55-74

25.我在我的书中详细介绍了退伍军人管理局的医院的背景和问题，见The Dis-carded Army：Veterans After Vietnam （New York：Charterhouse，1974），71-112。

26.Dan Feshbach,"What's Inside the Black Box:A Case Study of Allocative Politics in the Hill-Burton Program,"International Journal of Health Services 9 (19),313-339.27.Commission on Hospital Care,Hospital Care in the United States (New York:Commonwealth Fund,1947),411.

28.Feshbach，“What’s Inside the Black Box”；Herbert Klarman，“Planning for Fa-cilities，” in Regionalization and Health Policy，ed.Eli Ginzburg （Washington，D.C.：U.S.Government Printing Office，1973），27.另见 Frank J.Thomson，Health Politics and the Bureaucracy：Politics and Implementation （Cambridge，Mass.：MIT Press，1981），29-38。Ray Elling的一项案例研究表明，在Thomson所描述的共识表面之下，政治冲突非常激烈；见Ray H.Elling，“The Hospital-Support Game in Urban Center，”in The Hospital in Modern Society，ed.Eliot Freidson （New York：Free Press，1963），73-111。

29.U.S.Department of Health,Education and Welfare,Facts About the Hill-Burton Program,July 1,1947-June,30,1971;Judith R.Lave and Lester B.Lave,The Hospital Construction Act:An Evaluation of the Hill-Burton Program,1948-1973 (Washington,D.C.:American Enterprise Institute,1974).

30.然而，该计划并没有像其支持者最初预测的那样，成功地将医生吸引到低收入州。见Lawrence J.Clark et al，“The Impact of Hill-Burton：An Analysis of Hospi-tal Bed and Physician Distribution in the United States，1950-1970，”Medical Care 18 （May 1980），532-550。它也没有在各州内重新分配医生；见William A.Rushing，Community，Physicians and Inequality （Lexington，Mass.：Lexington Books，1975），200-203。

31.关于各社区的资金分配，见Lave and Lave，Hospital Construction Act，19-21；以及Jacquelyn Hochban et al.，“The Hill-Burton Program and Changes in Health Ser-vices Delivery，”Inquiry 8 （Spring 1981），61-69。De Vise指出，在实施希尔-伯顿计划的二十五年中，芝加哥没有一家城市内的医院得到援助，而郊区有二十多家医院在联邦援助下建成或扩大。见Pierre de Vise，Misused and Misplaced Hospitals and Doctors：A Locational Analysis of the Urban Health Care Crisis （Washington，D.C.：Asso-ciation of American Geographers，1973），76。

32.1949年，该法律被修订，要求调整地方出资的比例从高收入州的三分之二到低收入州的三分之一不等。因此，各州的人均收入在这个过程中发挥了两次作用：第一次在分配各州资金方面；第二次在确定地方赞助必须筹集的费用比例方面。

33.转引自Feshbach，“What’s Inside the Black Box，”326。

34.关于法律史的回顾，见Rand E.Rosenblatt，“Health Care Reform and Admin-istrative Law：A Structural Approach，” Yale Law Journal 88 （December 1978），264-286。

35.Don K.Price,"A Political Hypochondriac Looks at the Future of Medicine"(National Academy of Sciences,Washington,D.C.,May 9,1973).

36.Edward A.Shils,"The Autonomy of Science," in The Sociology of Science,ed.Bernard Barber and Walter Hirsch (New York:Free Press,1962),610-614.

37.Stevens,American Medicine and the Public Interest,350-351.

38.John E.Deitrick and Robert C.Berson,Medical Schools in the United States at Mid-century (New York:McGraw-Hill,1953),195;Patricia L.Kendall,The Relation-ship Between Medical Educators and Medical Practitioners (Evanston,Ill.:Association of American Medical Colleges,1965),32.

39.Robert G.Petersdorf,"The Evolution of Departments of Medicine," New Eng-land Journal of Medicine 303 (August 28,1980),491.

40.Vernon W.Lippard,A Half Century of Medical Education:1920-1970 (New York:Josiah Macy,Jr.,Foundation,1974),42-43.

41.Kendall,Relationship Between Medical Educators and Medical Practitioners,36,42,57.

42.Marcus S.Goldstein,Income of Physicians,Osteopaths and Dentists from Profes-sional Practice (Washington,D.C.:Social Security Administration,Office of Research and Statistics,1972).

43.Kendall,Relationship Between Medical Educators and Medical Practitioners,82.

44.Lippard,Half Century,47-48.

45.转引自Robert K.Merton，“Some Preliminaries to a Sociology of Medical Edu-cation，”in The Student Physician，ed.Robert K.Merton，George G.Reader，and Patri-cia L.Kendall （Cambridge：Harvard University Press，1957），24。

46.Patricia L.Kendall and Hanan C.Selvin，“Tendencies Toward Specialization in Medical Training，”in ibid.，153-174；学生日记转引自ibid.，163。

对六所公立和六所私立医学院1950年和1954年的毕业生进行的一项调查表明，私立院校的专业化趋势更为明显。Fremont J.Lyden，H.Jack Geiger，and Osler L.Peterson，The Training of Good Physicians：Critical Factors in Career Choices （Cam-bridge：Harvard University Press，1968）.

20世纪60年代末，至少在哈佛大学医学院，似乎也出现了从强调私人专科实践到科学工作的转变；当时正值公众对医学研究的支持高潮，也可能反映了斯普特尼克号发射后的总体氛围。见Daniel H.Funkenstein，Medical Students，Medical Schools and Society During Five Eras：Factors Affecting the Career Choice of Physicians 1958-1976 （Cambridge，Mass.：Ballinger，1978）。

47.Stevens，American Medicine and the Public Interest，203，244-257.另见Patricia L.Kendall，“Medical Specialization：Trends and Contributing Factors”in Psychosocial Aspects of Medical Training，ed.R.H.Coombs and C.E.Vincent （Springfield，Ill.：C.C Thomas，1971），449-497。

48.关于这些发展的讨论，见Stevens，American Medicine and the Public Interest，208-217，258-266；and Lippard，Half Century，93-95。

49.Stevens,American Medicine and the Public Interest,279-280.

50.J.A.Curran,"Internships and Residencies Historical Backgrounds and Current Trends,"Journal of Medical Education 34 (September 1959),873-884.

51.关于这些观点的佐证数据，请参见Roy Penchansky and Gerald Rosenthal，“Productivity，Price and Income Behavior in the Physicians’ Services Market—a Ten-tative Hypothesis，”Medical Care 3 （October-December 1965），240-244。

52.Mark S.Blumberg,"Physicians Fees as Incentives," in Changing the Behavior of the Physician:A Management Perspective (Proceedings of the Twenty-First Annual Symposium on Hospital Affairs,Graduate Program in Hospital Administration and Center for Health Administration Studies,Graduate School of Business,University of Chicago,June 1979),29-30.

53.Penchansky and Rosenthal,"Productivity,Price and Income Behavior."

54.Kendall，“Medical Specialization：Trends and Contributing Factors，”460.一个有趣的解释将专业声誉与医患关系的变化联系起来，见Stephen M.Shortell，“Oc-cupational Prestige Differences Within the Medical and Allied Health Professions，”Social Science and Medicine 8 （January 1974），1-9。

55.Surgeon General's Consultant Group on Medical Education,Physicians for a Growing America (Washington,D.C.:U.S.Government Printing Office,1959),8-11.

56.U.S.Department of Health Education and Welfare,Division of Public Health Methods,Health Manpower Source Book,vol.9,Physicians,Dentists and Professional Nurses,27.

57.Selwyn D.Collins，“Frequency and Volume of Doctors’ Calls Among Males and Females in 9000 Families，Based on Nationwide Periodic Canvasses，1928-31，”Public Health Reports 55 （November 1，1940），1977-2020；Antonio Ciocco，Isidore Altman and T.David Truan，“Patient Load and Volume of Medical Services，” Public Health Reports 67 June 1952），533.另见Bernhard J.Stern，American Medical Practice in the Perspectives of a Century （New York：Commonwealth Fund，1945）。

58.Raymond S.Duff and August B.Hollingshead,Sickness and Society (New York:Harper Row,1968),58.

59.U.S.Department of Health,Education and Welfare,Health Manpower Source Book,9:18,25.

60.Rosemary Stevens and Joan Vermeulen,Foreign Trained Physicians and Ameri-can Medicine (U.S.Department of Health Education and Welfare,1972),12.

61.John C.Nunemaker et al.,"Graduate Medical Education in the United States,"JAMA 174 (October 8,1960),578.

62.Alice M.Yohalem and Charles M.Brecher,"The University Medical Center and the Metropolis:A Working Paper,"in The University Medical Center and the Metrop-olis,eds.Eli Ginzburg and Alice M.Yohalem (New York:Josiah Macy,Jr.,Founda-tion,1974),10-13;"Graduate Medical Education:Annual Report on Graduate Medi-cal Education in the United States,"JAMA 226 (November 19,1973),930.

“帝国”一词来自John Ehrenreich and Barbara Ehrenreich，吀e American Health Empire：Power，Politics and Profits （New York：Random House，1970）。与其他任何一本书相比，这本书将注意力集中在医学院不断增长的势力及其与更大系统的关系上。但也许因为他们是以纽约市的视角来写的，我认为作者没有看到这一现象的历史和经济局限性。

63.Willard C.Rappleye,The Current Era of the Faculty of Medicine,Columbia Uni-versity,1910-1958 (New York:Columbia University Press,1958).

64.Duff and Hollingshead,Sickness and Society,46.

65.American Hospital Association，Hospital Statistics，1972 （Chicago：American Hospital Association，1972），190；另见Cecil G.Sheps et al.，Medical Schools and Hos-pitals：Interdependence for Education and Service （Evanston，Ill.：Association of Amer-ican Medical Colleges，1965），in Journal of Medical Education 40 （September 1965），pt.II，12。

66.这个框架我受惠于 Alfred E.Miller，“The Changing Structure of the Medical Profession in Urban and Suburban Settings，”Social Science and Medicine 11 （March 1977），233-243。

67.Hodgson,America in Our Time,7.

68.Surgeon General's Consultant Group on Medical Education,Physicians for a Growing America (Washington,D.C.:U.S.Government Printing Office,1959).

69.Milton I.Roemer and Max Shain,"Hospital Utilization Under Insurance,"mimeographed (Ithaca,N.Y.:Cornell University School of Business and Public Ad-ministration,1959),17-18,51.

70.U.S.Bureau of the Census,Historical Statistics of the United States,Colonial Times to 1970 (Washington,D.C.:U.S.Department of Commerce,1975),84.

71.关于这场辩论的回顾，见Andrew T.Scull，Decarceration （Englewood Cliffs，N.J.：Spectrum，1977）。

72.Joint Commission on Mental Illness and Health，Action for Mental Health （New York：Basic Books，1961）.关于历史背景，见Connery et al，Politics of Mental Health，37-47。

73.“Special Message to the Congress on Mental Illness and Mental Retardation，February 5，1963，”Public Papers of the President，John F.Kennedy，1963，126，128.关于该计划的研究，见Franklin D.Chu and Sharland Trotter，The Madness Establish-ment （New York：Grossman，1974） and Connery et al.，Politics of Mental Health。

74.James L.Sundquist,Politics and Policy:The Eisenhower,Kennedy and Johnson Years (Washington,D.C.:Brookings Institution,1968),13-56.

75.Daniel P.Moynihan,Maximum Feasible Misunderstanding:Community Action in the War on Poverty (New York:Free Press,1969).

76.联邦医疗保险的故事，见Theodore R.Marmor，The Politics of Medicare （Chicago：Aldine，1973）；Richard Harris，A Sacred Trust （New York：New American Library，1966）；以及Sundquist，Politics and Policy，287-321。

77.Harris,Sacred Trust,110-115,144;Marmor,Politics of Medicare,35-38.

78.Robert Stevens and Rosemary Stevens,Welfare Medicine in America:A Case Study of Medicaid (New York:Free Press,1974).

79.President's Commission on Heart Disease,Cancer and Stroke,Report to the President:A National Program to Conquer Heart Disease,Cancer and Stroke (Wash-ington,D.C.:U.S.Government Printing Office,1964),v.1,viii.

80.Drew,"Health Syndicate."

81.H.Jack Geiger，“Community Control—or Community Conflict，” in Neighbor-hood Health Centers，ed.Robert M.Hollister，Bernard M.Kramer，and Seymour S.Bellin （Lexington，Mass.：Lexington Books，1974），140.关于卫生中心的起源，见Sar Levitan，The Great Society’s Poor Law：A New Approach to Poverty （Baltimore：Johns Hopkins Press，1969），191-205；Lisbeth Bamberger Schorr and Joseph T.Eng-lish，“Back-ground，Context and Significant Issues in Neighborhood Health Center Programs，”Milbank Memorial Fund Quarterly 66 （July 1968），289-296，reprinted in Hollister et al，eds.，Neighborhood Health Centers，45-50；and Daniel I.Zwick，“Some Accomplishments and Findings of Neighborhood Health Centers，”in ibid.，69-90。

82.Karen Davis and Cathy Schoen,Health and the War on Poverty (Washington,D.C.:Brookings Institution,1978),164.

83.Ibid.,173-200.

84.后续发展，见“Community Health Centers—Fifteen Years Later，”Urban Health （April 1980），34-40。

85.Davis and Schoen,Health and the War on Poverty,41-48.

86.Karen Davis and Roger Reynolds，“The Impact of Medicare and Medicaid on Access to Medical Care，”in The Role of Health Insurance in the Health Services Sector，ed.Roger N.Rosett （New York：National Bureau of Economic Research，1976）.对于各计划及其效果的调查，见Charles E.Lewis，Rashi Fein，and David Mechanic，A Right to Health：The Problem of Access to Primary Medical Care （New York：Wiley，1976）。

87.U.S.Bureau of the Census，Characteristics of the Population Below the Poverty Level：1978，Series P-60，no.124，June 1980，16.1959年至1976年间，户主工作的贫困人口比例从68%下降到48%（ibid.，28）。即使不包括女户主家庭，也从75%下降到60%（ibid.，34）。

88.比较National Center for Health Statistics，Bed Disability Among the Chronical-ly Limited，United States July 1957-June 1961，Series 10，no.12，and U.S.Department of Health，Education and Welfare，Health：United States，1979，117-118。在1957—1961年，低收入者的“卧床残疾”天数比高收入者多66%，但在1972年，这样的天数多了123%。另见 Harold S.Luft，Poverty and Health：Economic Causes and Consequences of Health Problems （Cambridge，Mass.：Ballinger，1978）。在至少由丈夫和妻子组成的贫困家庭中，约有65%的家庭包括一名成年残疾人，而目前贫困的残疾人中，至少有30%的人是健康问题致贫的。

89.Aday和她的同事根据残疾天数调整医生服务的使用，发现到1976年，不同的收入水平之间不存在差异。然而，Kleinman借助1978年的一个更大范围的调查发现，根据另一个不同的需求指数—卧床残疾天数，高收入者的就医次数要高73%。卧床残疾指数可能更准确地反映了健康的差异。普通残疾天数显示出较少的收入差异，也许是因为高收入者包括了严重程度较低的疾病。见LuAnn Aday，Ronald Andersen，and Gretchen V.Fleming，Health Care in the U.S：Equita-ble for Whom？（Beverly Hills，Calif.：Sage Publications，1980）；Kleinman的数据见于Karen Davis，Marsha Gold and Diane Makuc，“Access to Health Care for the Poor：Does the Gap Remain？”Annual Review of Public Health 2 （1981），159-182。

关于等待时间和其他医疗服务获得情况指标的持续差异的证据，见Frank Sloan and Judith K.Bentkover，Access to Ambulatory Care and the U.S.Economy （Lexington，Mass.：Lexington Books，1979）。

90.Davis,Gold,and Makuc,"Access to Health Care for the Poor."

91.Davis and Schoen,Health and the War on Poverty,52-56.

92.Judith M.Feder，Medicare：The Politics of Federal Hospital Insurance （Lexing-ton，Mass.：Lexington Books，1977）.更早的研究见Herman Miles Somers and Anne Ramsay Somers，Medicare and the Hospitals：Issues and Prospects （Washington，D.C.：Brookings Institution，1966），154-196。

93.Klarman,"Planning for Facilities,"25-36.

94.关于规划和改革的局限性的另一个观点，见Robert Alford，Health Care Poli-tics：Ideological and Interest Group Barriers to Reform （Chicago：University of Chicago Press，1975）。

Alford提出了一个“结构性利益”的理论来解释他视作微不足道的医疗改革后果。关键的结构性利益是：（1）专业垄断，医生的利益和系统的“主导利益”；（2）公司的合理化，这是医学院系、医院行政人员、卫生规划人员和其他与机构有关的人员共同的“挑战性利益”；以及（3）健康平等，这是穷人和其他被忽视的人共同的“被压抑的”利益。Alford的论点是，医疗改革的失败源于专业垄断和公司合理化之间的僵局。

这种分析—或者至少是Alford引入的词汇—已经被证明对研究美国医疗的社会学家和政治学家有很大的说服力。这一研究路径代表了一种重要的贡献，但由于几个原因，我选择不使用它。

首先，“结构性利益”的概念就其抽象性而言几乎是形而上学的。Alford坚持认为，结构性利益不能与利益集团相混淆。“这个概念[结构性利益]在经验上对联盟形成和构成通常意义的利益集团的程度及条件保持开放。核心观点是，现有的制度对所有的职业、团体或组织发挥作用，而这些职业、团体或组织具有分类术语所指示的共同利益。”（Ibid.，14-15；强调由我所加。）但是，职业、团体和组织能否按照Alford所归结的共同结构性利益而得到明确地分类？将医院管理者归类为在结构上与私人医生的利益相对立的人，会产生一个重大困难。因为正如我在本章前面所论证的，社区医院和医生的利益是密切相关的。Alford假定，一些行政人员对区域化和其他“公司理性主义”改革的支持表明了所有行政人员的深层利益—或许我应该说是纯粹的、柏拉图意义上的行政结构利益。

还有更深层次的困难。Alford假设存在结构性利益，但他实际上写的是这些团体及其代表的信念。这本书在很大程度上是对建议重组纽约市卫生服务的各种报告的叙述。Alford对系统的实际经济关系鲜有论述，甚至对纽约也是如此；书中缺少对制度结构的任何持续的历史分析，因此，用来描述结构性利益的范畴是来自对意识形态差异的分析，而不是制度安排的。

此外，该书并没有令人信服地解释为什么假定的结构性利益会陷入僵局。Alford写道：“与其说是社会共识给了医生权力，不如说是医生的权力产生了社会共识。”（Ibid.，17）但医生的权力从何而来？该书留给我们的印象是，这种权力一直都在那里，是一种主要推动者。另一方面，我所采取的进路试图解释医疗系统的制度结构在历史上是如何产生的，包括医疗行业的权力是如何产生的。我不认为医生的利益在结构上是明确的（见我对进步主义时代医疗保险的失败的讨论），我强调政治决策在塑造制度演变中的决定性意义。改革的失败不能主要根据医学内部的利益分歧来理解；它可以追溯到一个更普遍的政治妥协模式。（更广泛的讨论见Paul Starr and Gösta Esping-Andersen，“Passive Intervention，”Working Papers for a New Society 7 [July-August 1979]，15-25。）

最后，Alford的“公司合理化”概念显然来自60年代末流行的“公司自由主义”的新左派理论。这种理论的潜在功能是诋毁自由主义者所提出的再分配改革方案。这些理论试图将此类改革与既定机构的潜在利益联系起来，然后证明这些机构首先造成了不平等或异化的问题。像这一时期的其他激进理论一样，Alford将自由主义改革的意义降到最低，并将其描述为仅仅是使公司秩序合理化的努力。在他的叙述中，根据定义，这些改革并不能满足穷人和其他需要医疗服务的人的利益；应该由经验确认的东西被写进了他的结构性利益分类中。“公司合理化”这个词在医疗方面确实有其用途—特别是用来描述医疗保健公司可能带来的各种合理化。（关于这些发展，见本部最后一章。）

95.强调美国医疗和阶级结构之间的对应关系的解释，见Vicente Navarro，Medi-cine Under Capitalism （New York：Prodist，1976）。

96.“结构性力量”这一概念，见Steven Lukes，Power：A Radical View （New York：Macmillan，1974）。

第四章 授权终止

1.U.S.Public Health Service,Office of Research,Statistics and Technology,Health:United States,1981 (Hyattsville,Md.:U.S.Department of Health and Human Servic-es,1981),263.

2.New York Times,July,11,1969.

3."$60-Billion Crisis in Health Care,"Business Week (January 17,1970),50-64.

4."It's Time to Operate,"Fortune 81 (January 1970),79.

5.Ronald Andersen,Joanna Kravits and Odin W.Anderson,"The Public's View of the Crisis in Medical Care:an Impetus for Changing Delivery Systems?"Economic and Business Bulletin 24 (1971),44-52.

6.Godfrey Hodgson,"The Politics of American Health Care,"Atlantic 232 (October 1973),55.

7.U.S.Public Health Service,Health:United States,1981,268-269.

8.Victor R.Fuchs，Who Shall Live？（New York：Basic Books，1974），92-95.最近对这些年的国家卫生支出的计算结果略高于此。见U.S.Public Health Service，Health：United States，1981，263。

9.Martin S.Feldstein,"Hospital Cost Inflation:A Study of Nonprofit Price Dy-namics,"American Economic Review 61 (December 1971),853-872.

10.U.S.Public Health Service,Health:United States,1981,270.

11.Thomas L.Delbanco,Katherine C.Meyers,and Elliot A.Segal,"Paying the Physician's Fee:Blue Shield and the Reasonable Charge," New England Journal of Medicine 301 (December 13,1979),1314-1320.

12.Mark S.Blumberg,"Physicians Fees as Incentives," in Changing the Behavior of the Physician:A Management Perspective (Proceedings of the Twenty-First Annual Symposium on Hospital Affairs,Graduate Program in Hospital Administration and Center for Health Administration Studies,Graduate School of Business,University of Chicago,June 1979),20-32.

13.Benson B.Roe,"The UCR Boondoggle:A Death Knell for Private Practice?"New England Journal of Medicine 305 (July 2,1981),41-45,and correspondence,ibid.30 (November 19,1981),1287-1288.

14.Louis A.Orsini,"Hospital Financing:PUBLIC ACCOUNTABILITY—The Case of Rates Prospectively Determined by State Agencies for All Patients," Viewpoint,Health Insurance Association of America (January 1974).

15.Alan A.Stone,Mental Health and the Law:A System in Transition (Rockville,Md.:National Institute of Mental Health,1975),83-96;George J.Annas,The Rights of Hospital Patients (New York:Discus Books,1975),3-9.

16.Annas,Rights of Hospital Patients,57-78.

17.William J.Curran,"The Patients'Bill of Rights Becomes Law," New England Journal of Medicine 290 (January 6,1974),32-33.

18.Jean Hamburger,The Power and the Frailty:The Future of Medicine and the Fu-ture of Man (New York:Macmillan,1973),83.

19.Sue Sprecher,"Psychosurgery Policy Soon to be Set," Real Paper,January 21,1978.

20.David J.Rothman,"The State as Parent:Social Policy in the Progressive Era,"in Willard Gaylin et al.,Doing Good:The Limits of Benevolence (New York:Pantheon,1978),69-95.

21.“Medical Education in the United States，1979-1980，” JAMA 244 （December26，1980），2814.女医生变化的证据，见Naomi Bluestone，“The Future Impact of Women on American Medicine，” American Journal of Public Health 68 （August 1978），760-763。

22.Sheryl Burt Ruzek,The Women's Health Movement:Feminist Alternatives to Medical Control (New York:Praeger,1978).

23.George J.Annas,"Homebirth:Autonomy vs.Safety,"Hastings Center Report 8 (August 1978),19-20.

24.Dan Cordtz,"Change Begins in the Doctor's Office," Fortune (January 1970),84.

25.转引自John K.Iglehart，“Prepaid Group Medical Practice Emerges as Likely Federal Approach to Health Care，”National Journal 3 （July 10，1971），1444。

26.对各种全民医疗保险提案的考察，见Karen Davis，National Health Insurance：Benefits，Costs and Consequences （Washington，D.C.：Brookings Institution，1975）。

27.Joseph Falkson，HMOs and the Politics of Health System Reform （Chicago：American Hospital Association，1980），10.下面的讨论经常借鉴Falkson和我自己在写作时对保罗·埃尔伍德和其他人的采访，“The Undelivered Health System，” The Public Interest，no.42 （Winter 1976），66-85。本章关于健康维护组织的一些段落最初出现在那篇文章中。

28.该文后来发表于Paul M.Ellwood，Jr.，et al.，“The Health Maintenance Strate-gy，”Medical Care 9 （June 1971），291-298。

29.New York Times,February 19,1971.

30.Carnegie Commission on Higher Education,Higher Education and the Nation's Health (New York:McGraw-Hill,1970).

31.New York Times,September 4,1971.

32."Can the A.M.A.recover from its political mistakes?"Medical Economics (Janu-ary 5,1970),27-39.

33.Walter C.Bornemeier，“Blueprint for the Future，” JAMA 217 （July 19，1971），324.关于美国医学会在20世纪70年代中期的困难，见John Carlova，“Going，Go-ing...AMA’s Grip on State Societies，”Medical Economics 52 （February 3，1975），33-42；New York Times，June 19，1975；and John K.Iglehart，“No More Dr.Nice Guy，”National Journal 8 （March 6，1976），313。

34.William J.Curran,National Survey and Analysis of Certificate of Need Laws:Health Planning and Regulation in State Legislatures (Chicago:American Hospital Association,1973).

35.American Hospital Association,Hospital Regulation:Report of the Special Com-mittee on the Regulatory Process (Chicago:American Hospital Association,1977).

36.New York Times,December 16,1972;Paul B.Ginsburg,"Inflation and the Eco-nomic Stabilization Program," in Health:A Victim or Cause of Infation,ed.Michael Zubkoff (New York:Prodist,1976),31-51.

37.Barbara Isenberg,"Physician Panels are Used Increasingly to Police Skyrocket-ing Costs of Treating the Aged,Needy,"Wall Street Journal,April 7,1972.

38.George Maddaloni,"PSRO—Relationships of Organized Medicine in PSRO [sic]"in Public Control of Medical Care:History,Practices and Problems of the Federal Professional Standards Review Organization,ed.Nathan Goldfarb,Hofstra University Yearbook of Business,Series 13,vol.2,121-189;Judith Axler Turner,"HEW Begins Medical Review;AMA,Hospitals Mount Opposition,"National Journal Reports 6 Jan-uary 19,1974),90-102.

39.John K.Iglehart,"Executive-legislative Conflict Looms over Continuation of Health Care Subsidies,"National Journal 5 (May 5,1973),645-652;"Executive-Con-gressional Coalition Seeks Tighter Regulation for Medical-Services Industry,"Nation-al Journal Reports 5 (November 10,1973),1684-1692.

40.Leonard S.Rosenfeld and Irene Rosenfeld,"National Health Planning in the United States:Prospects and Portents," International Journal of Health Services 5 (1975),441-453.

41.Russell B.Roth,M.D.,"A Bankrupt Law,"American Medical News (November 22,1976),10.

42.American Hospital Association,Hospital Regulation,15.

43.New York Times,February 8,1974.

44."Insuring the Nation's Health,"Newsweek,June 3,1974.

45.John K.Iglehart,"National Insurance Plan Tops Ways and Means Agenda,"National Journal Reports 6 (March 16,1974),383.

46.Alice M.Rivlin，“Agreed：Here Comes National Health Insurance，”New York Times Magazine，July 21，1974.另见John K.Iglehart，“Consensus Forms for National Insurance Plan，Proposals Vary Widely in Scope，” National Journal Reports 5 （December 12，1973），1855-1863；and idem，“Compromise Seems Unlikely on Three Major Insur-ance Plans，”National Journal Reports 6 （May 11，1974），700-707。

47.Executive Office of the President,Council on Wage and Price Stability,The Problem of Rising Health Care Costs (April 1976).

48.National Journal 8 (October 16,1976),1460.

49.John K.Iglehart,"The Rising Costs of Health Care—Something Must be Done,but What?"National Journal 8 (October 16,1976),

50.以下内容部分摘自我的文章，“The Politics of Therapeutic Nihilism，”Working Papers for a New Society 3 （Summer 1976），48-55。

51.Aaron Wildavsky,"Doing Better and Feeling Worse:The Political Pathology of Health Policy,"Daedalus 106 (Winter 1977),105,and John H.Knowles,"The Re-sponsibility of the Individual,"ibid.,57-80.

52.Ivan Illich,Medical Nemesis:The Expropriation of Health (New York:Pantheon,1976).

53.Victor R.Fuchs,Who Shall Live?Health,Economics and Social Choice (New York:Basic Books,1974).

54.David E.Rogers and Robert J.Blendon,"The Changing American Health Scene:Sometimes Things Get Better,"JAMA 237 (April 18,1977),1710-1714.

55.Karen Davis and Cathy Schoen,Health and the War on Poverty (Washington,D.C.:Brookings Institution,1978),26-35,184-185,219-224.

56.Illich,Medical Nemesis,242.

57.Joseph A.Califano,Jr.,Governing America (New York:Simon and Schuster,1981),97.

58.Theodore Marmor and Edward Tenner,"National Health Insurance:Canada's Path,America's Choice,"Challenge 20 (May-June 1977),13-21.

59.1979年5月与本·海涅曼（Ben Heineman，Jr.）的会面，当时我正为《新共和》写一篇文章。

60.David S.Salkever and Thomas W.Bice,"The Impact of Certificate of Need Controls on Hospital Investment," Milbank Memorial Fund Quarterly 54 (Spring 1976),185-214.

61.Brian Biles,Carl J.Schramm,and J.Graham Atkinson,"Hospital Cost Inflation Under State Rate Setting Programs,"New England Journal of Medicine 303 (September 18,1980),664-667.

62.Califano,Governing America,166-167;Falkson,HMO's,184-208.

63.对卫生系统局的两项研究，参见Drew Altman，Richard Greene，and Harvey M.Sapolsky，Health Planning and Regulation：The Decision-Making Process （Wash-ington，D.C.：AUPHA Press，1981）；and James A.Morone，“The Dilemma of Citizen Representation：Democracy，Planning and Bureaucracy in Local Health Politics.”（Ph.D.diss.，University of Chicago，1981）。

64.Alan Blum,"Family Practice On and Off the Campus," JAMA 245 (April 17,1981),1560-1561.

65.U.S.Department of Health and Human Services，National Center for Health Services Research，“Who Are the Uninsured？” Data Preview I （1980）.统计数据是1977—1978年度的。

66.Clark C.Havighurst，“Competition in Health Services：Overview，Issues and Answers，” Vanderbilt Law Review 34 （May 1981），115-178.Alain C.Enthoven，Health Plan：The Only Practical Solution to Soaring Health Costs （Reading，Mass.Addison-Wesley，1980）.另见Alain C.Enthoven，“How Interested Groups have Re-sponded to a Proposal for Economic Competition in Health Services，”American Eco-nomic Review 70 （May 1980），142-148。

67.New York Times,February 16,1981.

第五章 公司时代的来临

1."Medical Education in the United States,1979-1980,"JAMA 244 (December 26,1980),2813.

2.Congress of the United States,Office of Technology Assessment,Forecast of Phy-sician Supply and Requirements (Washington,D.C.:U.S.Government Printing Office,April 1980),22.

3.Ibid.,7-12.

4.U.S.Dept.of Health and Human Services,Summary Report of the Graduate Med-ical Educational National Advisory Committee (Washington,D.C.:U.S.Government Printing Office,1980),I:3,67.

5.见Kathryn Langwell在一项尚未发表的研究中提供的数据，以及附带的注意事项，Uwe E.Reinhardt，“The GMENAC Forecast：An Alternative View，”American Journal of Public Health 71 （October 1981），1151-1152。

6.关于“倦怠”和“远离病人”，见Martin R.Lipp，The Bitter Pill （New York：Harper Row，1980），Chaps.1，11-15。

7.Gerald L.Glandon and Jack L.Werner,"Physicians'Practice Experience During the Decade of the 1970s,"JAMA 244 (December 5,1980),2518.

8.National Center for Health Statistics,Current Estimates from the Health Inter-view Survey:United States-1979,Series 10,no.136 (Hyattsville,Md.:U.S.Department of Health,Education and Welfare,1981),4.

9.Arthur Owens,"Working at Full Capacity?A Lot of Your Colleagues Aren't,"Medical Economics 56 (April 2,1979),63 ff.

10.Jack Hadley et al.,"Can Fee-for-Service Coexist with Demand Creation?" In-quiry 16 (Fall 1979),247-258.

11.Gerald L.Glandon and Roberta J.Shapiro,"Trends in Physicians'Incomes,Expenses and Fees:1970-1979," in Profile of Medical Practice 1980,ed.Gerald L.Glandon and Roberta J.Shapiro (Chicago:American Medical Association,1980),39-49;"Earnings Survey,"Medical Economics 57 (September 15,1980),120-121.

12.Harry T.Paxton,"Group Practice Jobs:Suddenly It's a Buyer's Market,"Medi-cal Economics 56 (November 26,1979),27-34.

13.Victor R.Fuchs,"The Coming Challenge to American Physicians," New Eng-land Journal of Medicine 304 (June 11,1981),1487-1490.

14.关于拥有众多医生的城市的一些报告，见John H.Lavin，“Doctor Surplus：Close-Up of a Town that’s Feeling the Crunch，” Medical Economics （September 29，1980），69-80；and Marilyn Chase，“City of Doctors：Will Surplus of M.D.’s Be Good for Patients？Look at San Francisco，”Wall Street Journal，March 13，1980。

15.Milton I.Roemer，Jorge A.Mera，and William Shonick，“The Ecology of Group Medical Practice in the United States，” Medical Care 12 （August 1974），627-637.关于团体的早期发展，见上部第六章。

16.Jeff Charles Goldsmith,Can Hospitals Survive?The New Competitive Health Care Market (Homewood,Ill.:Dow Jones-Irwin,1981),35-36.

17.Ibid.,46,136-144.

18.Paul M.Ellwood and Linda Krane Ellwein,"Physician Glut Will Force Hospi-tals to Look Outward,"Hospitals (January 16,1981),81-85.

19.Ibid.，83-84.另 见 Marla Salmon White and Richard A.Culbertson，“The Over-supply of Physicians：Implications for Hospital Planning，”Hospital Progress 62 （February 1981），28-31。

20.American Medical Association，“Federal and Non-Federal Physicians，By AMA Membership，Sex and State，”November 23，1981（美国医学会提供）.

21."Report of the Ad Hoc Committee on Women Physicians in Organized Medi-cine,"American Medical Association,1980.

22.1981年1月15日于芝加哥的会面。

23.《财富》杂志和激进的卫生政策咨询委员会（Health-PAC）都使用了这个词。见 Harold B.Meyers，“The Medical Industrial Complex，” Fortune 81 （January 1970），90ff，and John Ehrenreich and Barbara Ehrenreich，The American Health Em-pire （New York：Random House，1970），95-123。

24.Arnold S.Relman,"The New Medical-Industrial Complex,"New England Jour-nal of Medicine 303 (October 23,1980),963-970.

25.David B.Starkweather,Hospital Mergers in the Making (Ann Arbor,Mich.:Health Administration Press,1981),5.

26.Donald E.L.Johnson and Vince diPaolo,"Multihospital System Survey,"Mod-ern Healthcare 11 (April 1981),80.Montague Brown et al.,"Trends in Multihospital Systems:A Multiyear Comparison," Health Care Management Review 6 (Fall 1980),9-22.

尽管两者都发现医院集团系统中有大约30万张床位，但这两项调查实际上测量的是一些不同的统计数据。《现代医疗保健》的调查仅限于集中管理的系统，而美国医院协会的调查则包括许多医院只是松散的附属机构的系统。然而，《现代医疗保健》的调查包括那些由连锁机构管理但并不由其所有的医院，而美国医院协会的调查似乎仅限于连锁机构拥有的医院。这些定义上的差异显然在所计算的总床位数中被抵消了。然而，它们产生了对医院集团部门构成的不同评估，因为营利性医院更多是集中管理的，而且它们也占了合同管理下的大部分医院。

27.Brown et al.,"Trends in Multihospital Systems,"21.

28.Johnson and diPaolo,"Multihospital System Survey,"96.

29."Management Company Expansion Spurs Investor-Owned Growth,"Federation of American Hospitals Review 14 (November-December 1981),54-55.

30.Marilyn Mannisto,"Hospital Management Companies Expand Foreign Oper-ations," Hospitals 55 (February 1,1981),52-56.Hospital Corporation of America,Annual Report,1980.

31.Gwen Kinkead,"Humana's Hard-Sell Hospitals," Fortune (November 17,1980),68-81.

32.American Hospital Association,Hospital Statistics,1981 (Chicago:American Hospital Association,1981),6-7;Johnson and diPaolo,"Multihospital System Sur-vey,"96;Bruce Steinwald and Duncan Neuhauser,"The Role of the Proprietary Hos-pital,"Law and Con-temporary Problems 35 (Autumn 1970),824.

33.Janet Bly and William P.Pierskalla，“Religious Systems’ Local Boards Have More Decision-making Power，”Modern Healthcare 11 （April 1981），88-89，91.美国医院协会的调查根据集中化程度对系统进行分类，发现“管理型”系统占所有社区医院床位的21%，而“附属型”系统仅占10%。1975年至1979年间，医院集团系统的增长主要发生在管理型系统中。Brown et al.，“Trends in Multihospital Sys-tems，”15-16.

34.Bly and Pierskalla，“Religious Systems’ Local Boards Have More Decision-mak-ing Power.”由内部董事控制，见Edward Herman，Corporate Power，Corporate Con-trol （New York：Cambridge University Press，1981）。

管理上的控制并不一定像一些管理革命的理论家所认为的那样，意味着公司更致力于增长而不是利润。内部董事通常持有大量的公司股份；他们作为管理者的成功取决于保持公司的市盈率。因此，即使经理人控制了公司，他们对所有权利益的投入也不会减少。

35.Johnson and diPaolo,"Multihospital System Survey."

36.Ibid.,81.

37.Robert Derzon,Lawrence S.Lewin,and J.Michael Watt,"Not-for-profit Chains Share in Multihospital System Boom,"Hospitals (May 16,1981),65-71.

38.Starkweather,Hospital Mergers,12-17.

39.Thomas F.Treat,"The Performance of Merging Hospitals," Medical Care 14 (March 1976),199-209.

40.David B.Starkweather,"U.S.Hospitals:Corporate Concentration vs.Local Community Control,"Public Affairs Report,Bulletin of the Institute of Governmental Studies,University of California,Berkeley,22 (April 1981),6.

41.Lawrence S.Lewin，Robert A.Derzon，and Rhea Margulies，“Investor-owneds and Nonprofits Differ in Economic Performance，” Hospitals （July 1，1981），52-58.关于一些有利于营利性医院的微弱证据，见Carson W.Bays，“Cost Comparisons of Forprofit and Nonprofit Hospitals，” Social Science and Medicine 13C （December 1979），219-225。

42.Brown et al.,"Trends in Multihospital Systems,"17-20.

43.S.David Pomrinse,"Voluntary Planning Forestalls Excessive Competition,Reg-ulation,"Hospital Progress 62 (March 1981),37.

44.Derzon,Lewin,and Watt,"Not-for-profit Chains,"66-67.

45.Vince diPaolo,"Gloomy Economic Prospects Will Spur Hospital Acquisition Market,"Modern Healthcare 11 (January 1981),70.

46.Starkweather,"U.S.Hospitals:Corporate Concentration vs.Community Con-trol,"6.

47.Barry Bluestone and Bennett Harrison,"Why Corporations Close Profitable Plants,"Working Papers for a New Society 7 (June 1980),15-23.

48.Kinkead,"Humana's Hard-Sell Hospitals,"70.

49.Ibid.,81.

50.Montague Brown,"Systems Diversify with Ventures Outside the Hospital,"Hospitals (April 1,1981),147-153.

51.Donald E.L.Johnson,"Nonprofit's Taxed Unit Can Sell Stock," Modern Healthcare (June 1981),90-92.Sally Berger,"Innovative Background Triggered Trus-tees'Interest in Conglomerate,"Modern Healthcare 11 (February 1981),108,110.

52.Sheila L.Simler,"Leading Hospitals Restructure,Even Though Benefits May Be Short-lived,"Modern Healthcare 11 (March 1981),68-73.

53.Dan Ruck,"Young System Races into Growth Program,"Modern Healthcare 11 (June 1981),60-64.

54.Paul A.Teslow，转引自Donald E.L.Johnson，“Nonprofits Will Merge，Add Services in the 1980’s，”Modern Healthcare 11 （May 1981），66。

55.Esther Fritz Kuntz,"Nursing Home Chains Buy Up Smaller Groups," Modern Healthcare 11 (June 1981),68-74;Relman,"New Medical-Industrial Complex,"964.

56.Eleanor Siegel,"Emergence of Emergicenters," Boston Globe,June 8,1981.Howard Eisenberg,"Convenience Clinics':Your Newest Rival for Patients?"Medical Economics (November 24 1980),71-84;Linda A.Burns and Mindy S.Ferber,"Free-standing Emergency Care Centers Create Public Policy Issues," Hospitals (May 16,1981),73-76.

57.Starkweather,"U.S.Hospitals:Corporate Concentration vs.Local Community Control,"1.

58.Richard L.Johnson,"Health Care 2000 A.D.:The Impact of Conglomerates,"Hospital Progress 62 (April 1981),48-53.

59.David A.Stockman,"Premises for a Medical Market Place:A Neoconservative's Vision of How to Transform the Health System,"Health Affairs 1 (Winter 1981),16.

60.关于对该证据的严格分析，见Harold S.Luft，Health Maintenance Organiza-tions：Dimensions of Performance （New York：Wiley，1981）。健康维护组织的竞争影响的一些进一步证据，见Jon B.Christianson，“The Impact of HMOs：Evidence and Research Issues，” Journal of Health Politics，Policy and Law 5 （Summer 1980），354-357。

61.Stephen Shortell,"The Researcher's View," in Hospitals in the 1980s:Nine Views (Chicago:American Hospital Association,1977).

62.Alfred Chandler,The Visible Hand:The Managerial Revolution in American Business (Cambridge:Harvard University Press,1977),315.

63.Daniel S.Greenberg，“Renal Politics，” New England Journal of Medicine 298 （June 22，1978），1427-1428；医学教授的话转引自John K.Iglehart，“Kidney Treat-ment Problem Readies HEW for National Health Insurance，”National Journal （June 26，1976），900。

64.Gina Bari Kolata,"NMC Thrives Selling Dialysis,"Science 208 (April 25,1980),379-382.

65.Paul W.Earle，“Business Coalitions—A New Approach to Health Care Cost Containment.” （American Medical Association，January 1982）；关于商业界观点的两份报告，见John Iglehart，“Health Care and American Business，” New England Journal of Medicine 306 （January 14，1982），120-124，and idem，“Drawing the Lines for the Debate on Competition，”New England Journal of Medicine 305 （July 30，1981），291-296。商业界对卫生保健成本并不真的那么感兴趣的怀疑观点，见Harvey M.Sapolsky，“Corporate Attitudes toward Health Care Costs，” Milbank Memorial Fund Quarterly 59 （Fall 1981），561-585。

66.American Medical Association,SMS Report [Sociomedical Monitoring System] (February 1982),1.

67.Goldsmith,Can Hospitals Survive?,33-34.

68.Interview,January 15,1982.

69.Clark Havighurst,"Professional Restraints on Innovation in Health Care Fi-nancing,"Duke Law Journal (May 1978),303-387.

70.Kinkhead,"Humana's Hard-Sell Hospitals,"76.

71.Johnson,"Health Care 2000 A.D,"49-50.

72.弗雷德森区分了医生在决定其工作“内容”方面的“技术”自主权和他们在控制工作组织或工作“条件”方面的社会和经济自主权。Eliot Freidson，Profession of Medicine （New York：Dodd，Mead，1970），373.随着法人组织将技术标准变为它们的修改对象，这种区分可能变得越来越站不住脚。

结语 连锁反应（1982—2016）

1.19篇批评文章和我的回应，见“Transforming American Medicine：A Twen-ty-Year Retrospective on The Social Transformation of American Medicine，” special issue，ed.Keith Wailoo，Timothy Stoltzfus Jost，and Mark Schlesinger，Journal of Health Politics，Policy and Law 29，nos.4-5 （August-October 2004）。

2.Michael Rothschild and Joseph Stiglitz,"Equilibrium in Competitive Insurance Markets:An Essay on the Economics of Imperfect Information,"Quarterly Journal of Economics 90 (1976),629-649.

3.见上文第414—415页。关于这一时期及之后卫生保健成本增长的波动，见Drew Altman and Larry Levitt，“The Sad History of Health Care Cost Containment as Told in One Chart，”Health Affairs （2002），w83-w84。

4.David Cutler,"Cost Shifting or Cost Cutting?The Incidence of Reductions in Medicare Payments,"Tax Policy and the Economy 12 (1998),1-27.

5.Rick Mayes and Robert A.Berenson,Medicare Prospective Payment and the Shaping of U.S.Health Care (Baltimore:Johns Hopkins Press,2006),2.

6.Lynn R.Gruber,Maureen Shadle,and Cynthia L.Polich,"From Movement to Industry:The Growth of HMOs,"Health Affairs 7 (1988),197-208.

7.转引自Anne R.Somers，“And Who Shall Be the Gatekeeper？The Role of the Primary Physician in the Health Care Delivery System，” Inquiry 20 （Winter 1983），301-313。

8.Kaiser Foundation and Health Research and Education Trust (HRET),Employer Health Benefits:2015 Annual Survey (Menlo Park,Calif.,and Chicago,Ill.:Kaiser and HRET,2015),79.

9.Arizona v.Maricopa Medical Society,457 U.S.332 (1982).

10.Rothschild and Stiglitz，“Equilibrium in Competitive Insurance Markets”；在医疗保险上的应用，见Mark Pauly and Sean Nicholson，“Adverse Consequences of Adverse Selection，”Journal of Health Politics，Policy，and Law 24 （1999），921-930。

11.Jack Needleman,"Nonprofit to For-Profit Conversions by Hospitals,Health Insurers and Health Plans,"Public Health Reports 114 (March-April 1999),108-119.

12.Thomas G.McGuire,Joseph P.Newhouse,and Anna D.Sinaiko,"An Economic History of Medicare Part C,"Milbank Quarterly 89 (2011),289-332.

13.Kaiser Commission on Medicaid and the Uninsured,"Medicaid and Managed Care," December 2001,https://kaiserfamilyfoundation.files.wordpress.com/2013/01/medicaid-and-managed-care-fact-sheet.pdf.

14.Robert J.Blendon and Karen Donelan,"The Public and the Emerging Debate over National Health Insurance," New England Journal of Medicine (July 19,1990),208-212;Joel Cantor et al.,"Business Leaders'Views on American Health Care,"Health Affairs 10 (1991),100.

15.Paul Starr，Remedy and Reaction：The Peculiar American Struggle over Health Care Reform （New Haven，CT：Yale University Press，2011，rev.ed.2013），chaps.3-4.我早先的著作（The Logic of Health Care Reform，Grand Rounds Press，1992，已经陈述了后来成为克林顿计划的方案；在两年后的修订版中（Penguin for Whittle Books，1994），该书对克林顿提案做了详细的阐述和辩护。其他叙述见Jacob S.Hacker，The Road to Nowhere （Princeton，NJ：Princeton University Press，1996）；The-da Skocpol，Boomerang （New York：W.W.Norton，1996）；Haynes Johnson and David S.Broder，The System （Boston：Little，Brown，1996）。

16.关于恩托文的计划，见Alain Enthoven and Richard Kronick，“A Consumer-Choice Health Plan for the 1990s，” parts 1 and 2，New England Journal of Medicine320 （January 5 and 12，1989），29-37，94-101。关于与克林顿提案的区别，见Paul Starr，“Why the Clinton Plan Is Not the Enthoven Plan，”Inquiry 31 （Summer 1994），136-140。

17.在一个最不为人所知的条款中，该计划根据每个公司的平均工资和规模对个别雇主的付款设定上限，以使负担更接近工资税，并减少对小企业的影响。雇主支付的几乎所有费用最终都用于员工身上，一个直接基于保费的系统比工资税的累退程度更高，而工资税是与工资成正比的。克林顿计划中的“限额保费”是一种尝试，希望获得工资税的优势，同时不影响美国人认为他们正在支付“保费”而不是“税”的感觉。但事实证明，这太复杂了，难以传达。

18.希拉里·克林顿的作为更是少之又少，见Paul Starr，“The Hillarycare My-thology，”The American Prospect （October 2007），12-18。

19.Altman and Levitt,"The Sad History of Health Care Cost Containment as Told in One Chart."

20.Robert J.Blendon et al.,"Understanding the Managed Care Backlash," Health Affairs 17,no.4 (July-August 1998),80-94;David Mechanic,"The Managed Care Backlash:Perceptions and Rhetoric in Health Care Policy and the Potential for Health Care Reform,"Milbank Quarterly 79 (2001),35-54.

21.Pauly and Nicholson,"Adverse Consequences of Adverse Selection,"927.

22.Lucian L.Leape，“Error in Medicine，” JAMA 272 （December 21，1994），1851-1857；Linda T.Kohn，Janet M.Corrigan，and Molla S.Donaldson，eds.，To Err Is Human：Building a Safer Health System （Washington，D.C.：National Academies Press，1999）.关注质量在早期的重要影响，见John Z.Ayanian and Howard Markel，“Donabedian’s Lasting Framework for Health Care Quality，”New England Journal of Medicine 375 （2016），205-207。

23.M.Gregg Bloche and David M.Studdert,"A Quiet Revolution:Law as an Agent of Health System Change,"Health Affairs 23,no.2 (2004),29-42.

24.William M.Sage,"Antitrust Enforcement and the Future of Healthcare Compe-tition,"in Oxford Handbook of U.S.Health Law,ed.I.Glenn Cohen,Allison K.Hoff-man,and William M.Sage (New York:Oxford University Press,2017),614.

25.Gary L.Reback,Free the Market!Why Only Government Can Keep the Market-place Competitive (New York:Portfolio,2009).

26.John E.McDonough,"Tracking the Demise of State Hospital Rate Setting,"Health Affairs 16,no.1 (1997),142-149.

27.截至2009年，根据世界卫生组织的数据，新西兰是仅有的另一个允许直接面向消费者的制药广告的国家。见 “Direct-to-Consumer Advertising Under Fire，”Bulletin of the World Health Organization （2009），87：576-577。

28.William B.Vogt and Robert Town,"How Has Hospital Consolidation Affected the Price and Quality of Hospital Care?," (Princeton,N.J.:Robert Woods Johnson Foundation,February 1,2006),http://www.rwjf.org/content/dam/farm/reports/is-sue_briefs/2006/rwjfl2056/subassets/rwjfl2056_l.

29.Ibid.

30.Cara S.Lesser and Linda R.Brewster,"Hospital Mergers and Their Impact on Local Communities," in Understanding Health System Change,ed.Paul B.Ginsburg and Cara S.Lesser (Chicago:Health Administration Press,2001),19-36.

31.Jack Needleman,"Nonprofit to For-Profit Conversions by Hospitals,Health Insurers,and Health Plans," Public Health Reports 114 (March-April 1999),108-119;Alison Evans Cuellar and Paul J.Gertler,"Trends in Hospital Consolidation:The Formation of Local Systems,"Health Affairs 22 (2003),77-87.

32.Jill R.Horwitz，“Making Profits and Providing Care：Comparing Nonprofit，For-Profit，and Government Hospitals，” Health Affairs 24 （2005），790-801.关于不同类型医院的道德环境的比较分析，见Adam Reich，Selling Our Souls：The Com-modification of Health Care in the United States （Princeton，NJ：Princeton University Press，2014）。

33.Frank A.Sloan,Jan Ostermann,and Christopher J.Conover,"Antecedents of Hospital Ownership Conversions,Mergers,and Closures,"Inquiry 40 (Spring 2003),39-56.

34.Lesser and Brewster,"Hospital Mergers and Their Impact on Local Communi-ties."

35.Vogt and Town,"How Has Hospital Consolidation Affected the Price and Quality of Hospital Care?"

36.Leemore Dafny,Mark Duggan,and Subramaniam Ramanarayanan,"Paying a Premium on Your Premium?Consolidation in the U.S.Health Insurance Industry,"American Economic Review 102 (2012),1161-1185.

37.Cara S.Lesser and Paul B.Ginsburg,"Introduction," in Understanding Health System Change,ed.Paul B.Ginsburg and Cara S.Lesser (Chicago:Health Administra-tion Press,2001),xv.

38.James C.Robinson,"The End of Managed Care," JAMA 285 (May 23-30,2001),2622-2628.

39.Centers for Medicare and Medicaid Services,National Health Expenditure Ac-counts,"NHEGDP14," https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHeaithAccount-sHistorical.html.

40.对于1980年和2000年，我使用了国家健康访谈调查的系列数据：Robin A.Cohen，“Health Insurance Coverage Trends，1959-2007：Estimates from the National Health Interview Survey，”National Health Statistics Reports no.17 （U.S.Department of Health and Human Services，Centers for Disease Control and Prevention，July 1，2009），9.关 于 2010 年，见 Michelle Long et al.，“Trends in Employer-Sponsored Insurance Offer and Coverage Rates，1999-2014” （Menlo Park，Calif.：Kaiser Family Foundation，March 2016），5。当前人口调查提供的2000年（65.1%）和2010年（55.3%）的估值略低于此：U.S.Bureau of the Census，Income，Poverty，and Health Insurance Coverage in the United States：2010 （Washington，D.C.，2011），Appendix C，Table Cl.

41.一般性讨论，见Jacob Hacker，The Great Risk Shift （New York：Oxford Uni-versity Press，2006）。

42.Kaiser Foundation and HRET，Employer Health Benefits：2015 Annual Survey，79.关于健康储蓄账户背后运动的一般背景，见Timothy Stoltzfus Jost，Health Care at Risk：A Critique of the Consumer-Driven Movement （Durham，NC：Duke University Press，2007）；Starr，Remedy and Reaction，151-154。

43.关于风险选择，见M.Kate Bundorf，“Consumer-Directed Health Plans：A Re-view of the Evidence，”Journal of Risk and Insurance 83 （2016），9-41。

44.Gary Claxton,Larry Levitt,and Michelle Long,"Payments for Cost-Sharing In-creasing Rapidly over Time,"Peterson-Kaiser Health System Tracker,April 12,2016,http://www.healthsystemtracker.org/insight/payments-for-cost-sharing-increasing-rapidly-over-time/.

45.Robin A.Cohen and Michael E.Martinez，“Health Insurance Coverage：Ear-ly Release of Estimates from the National Health Interview Survey，January-March 2015，”National Health Interview Survey Early Release Program （National Center for Health Statistics，August 2015），figure 11.高自付额计划“在2015年被定义为一项私人医疗保险计划，年度自付额本人保险至少为1300美元，家庭保险至少为2600美元”。

46.Sara R.Collins et al.,"Too High a Price:Out-of-Pocket Health Care Costs in the United States" (New York:Commonwealth Fund,2014),http://www.common-wealthfund.org/publications/issue-briefs/2014/nov/out-of-pocket-health-care-costs.

47.James C.Robinson and Paul B.Ginsburg,"Consumer-Driven Health Care:Promise and Performance,"Health Affairs 28 (January 27,2009),w272-w281.

48.Gerard F.Anderson et al.,"It's the Prices,Stupid:Why the United States Is So Different from Other Countries," Health Affairs 22 (2003),89-105;David Squires and Chloe Anderson,"U.S.Health Care from a Global Perspective"(New York:Com-monwealth Fund,October 2015),http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective.

49.Health Care Cost Institute,"Spending on Shoppable Services in Health Care,"Issue Brief no.11 (Washington,D.C.,March 2016),http://www.healthcostinstitute.org/files/Shoppable%20Services%20IB%203.2.16_0.pdf;Zarek C.Brot-Goldberg et al.,"What Does a Deductible Do?The Impact of Cost-Sharing on Health Care Prices,Quantities,and Spending Dynamics,"National Bureau of Economic Research,Work-ing Paper 21632 (2015).

50.National Institute for Health Care Management Foundation，“The Concentra-tion of Health Care Spending，” （Washington，D.C.，2012），1-2，http：//www.nihcm.org/pdf/DataBrief3%20Final.pdf.这些估值基于2009年医疗支出小组调查。

51.Gretchen Jacobson et al.,"Medicare Advantage 2016 Spotlight:Enrollment Market Update," Issue Brief (Menlo Park,Calif.:Kaiser Family Foundation,May 2016).

52.Andrew S.Kelly,"Boutique to Booming:Medicare Managed Care and the Private Path to Policy Change,"Journal of Health Politics,Policy,and Law 41 (2016),315-354.

53.Debra A.Draper,Robert E.Hurley,and Ashley C.Short,"Medicaid Managed Care:The Last Bastion of the HMO?"Health Affairs 23 (March 2004),155-167.

54.Cohen，“Health Insurance Coverage Trends，1959-2007：Estimates from the National Health Interview Survey，” 4.国家健康访谈调查和儿童保护服务都低估了联邦医疗补助的覆盖率，因此这些数据应被视为保守的。

55.U.S.Bureau of the Census,Income,Poverty,and Health Insurance Coverage in the United States:2010 (Washington,D.C.,2011),Appendix C,Table Cl.

56.Congressional Budget Office,"How Many People Lack Health Insurance and for How Long?"(2003),http://www.cbo.gov/ftpdocs/42xx/doc4210/05-12-Uninsured.pdf;Cathy Schoen et al.,"How Many Are Underinsured?Trends Among U.S.Adults,2003 and 2007," Health Affairs 27 (2008),w298-w309;John Holahan and Allison Cook,"The U.S.Economy and Changes in Health Insurance Coverage,2000-2006,"Health Affairs 27 (2008),w135-w144.

57.关于“美国医疗政策陷阱”，见Starr，Remedy and Reaction，esp.10-11。

58.National Federation of Independent Business v.Sebelius,567 U.S.___(2012).

59.关于《平价医疗法》效果的这些及其他论点的总结，见 Barack Obama，“United States Health Care Reform：Progress to Date and Next Steps，”JAMA 316 （July 11，2016），E1-E8。

60.Jon R.Gabel et al.,"More Than Half of Individual Health Plans Offer Coverage That Falls Short of What Can Be Sold Through Exchanges as of 2014,"Health Affairs 31 (2012),1339-1348.

61.Sara R.Collins et al.,"Americans'Experiences with ACA Marketplace and Medicaid Coverage:Access to Care and Satisfaction:Findings from the Common-wealth Fund Affordable Care Act Tracking Survey,February-April 2016"(New York:Commonwealth Fund,May 25,2016),http://www.commonwealthfund.org/publica-tions/issue-briefs/2016/may/aca-tracking-survey-access-to-care-and-satisfaction.

62.Benjamin D.Sommers et al.,"Changes in Utilization and Health Among Low-Income Adults After Medicaid Expansion or Expanded Private Insurance," JAMA Internal Medicine 176,no.10 (August 8,2016),1501-1509;Benjamin D.Sommers et al.,"Changes in Self-Reported Insurance Coverage,Access to Care,and Health Under the Affordable Care Act,"JAMA 314,no.4 (July 28,2015),366-374;Nicole Dussault,Maxim Pinkovskiy,and Basit Zafar,"Is Health Insurance Good for Your Financial Health?"Federal Reserve Bank of New York,June 6,2016,http://libertystreeteconom-ics.newyorkfed.org/2016/06/is-health-insurance-good-for-your-financial-health.html.

63.Ashley Kirzinger,Elise Sugarman,and Mollyann Brodie,"Kaiser Health Track-ing Poll:June 2016," June 30,2016,http://kff.org/global-health-policy/poll-finding/kaiser-health-tracking-poll-june-2016/.

64.Ashley Kirzinger,Bryan Wu,and Mollyann Brodie,"Kaiser Health Tracking Poll:September 2016"(Menlo Park,Calif.:Kaiser Family Foundation,September 29,2016),http://kff.org/health-costs/report/kaiser-health-tracking-poll-september-2016/.

65.Globe Spotlight Team,"A Handshake That Made Healthcare History," Boston Globe,December 28,2008,https://www.bostonglobe.com/specials/2008/12/28/hand-shake-that-made-healthcare-history/QiWbywqb8olJsA3IZl1o1H/story.html.

66.Bradley C.Strunk,Kelly J.Devers,and Robert E.Hurley,Health Plan-Provider Showdowns on the Rise,Issue Brief no.40 (Washington,D.C.:Center for Studying Health System Change,June 2001).

67.David M.Cutler and Fiona Scott Morton,"Hospitals,Market Share,and Con-solidation,"JAMA 310 (November 13,2013),1964-1970.

68.Martin Gaynor and Robert J.Town,"Competition in Health Care Markets,"Working Paper 17208 (National Bureau of Economic Research,July 2011),http://www.nber.org/papers/w17208.

69.Martin Gaynor,"Consolidation and Competition in U.S.Health Care,"Health Af-fairs Blog,March 1,2016,http://healthaffairs.org/blog/2016/03/01/new-health-care-sym-posium-consolidation-and-competition-in-us-health-care/.

70.Robert A.Berenson et al.,"The Growing Power of Some Providers to Win Steep Payment Increases from Insurers Suggests Policy Remedies May Be Needed,"Health Affairs 31 (May 1,2012),973-981.

71.Paul B.Ginsburg,"Wide Variation in Hospital and Physician Payment Rates Evidence of Provider Market Power," Research Brief no.16 (Washington,D.C.:Center for Studying Health System Change,November 2010).

72.Office of Massachusetts Attorney General Martha Coakley,"Investigation of Health Care Cost Trends and Cost Drivers,Pursuant to G.L.c.118G,§ 6 1/2(b)"(Boston,Mass.,March 16,2010).

73.Zack Cooper et al.,"The Price Ain't Right?Hospital Prices and Health Spend-ing on the Privately Insured" (Cambridge,Mass.:National Bureau of Economic Re-search,December 2015).

74.Robert A.Berenson,Paul B.Ginsburg,and Nicole Kemper,"Unchecked Pro-vider Clout in California Foreshadows Challenges to Health Reform," Health Affairs 29,no.4 (April 2010),1-7.

75.Thomas M.Selden,Zeynal Karaca,Patricia Keenan,Chapin White,and Richard Kronick,"The Growing Difference Between Public and Private Payment Rates for In-patient Hospital Care,"Health Affairs 34 (2015),2147-2150.

76.Chapin White，“Contrary to Cost-Shift Theory，Lower Medicare Hospital Payment Rates for Inpatient Care Lead to Lower Private Payment Rates，”Health Affairs 32 （2013），935-943；另见Austin B.Frakt，“Hospitals Are Wrong About Shifting Costs to Private Insurers，”New York Times，March 23，2015；and Frakt，“How Much Do Hospitals Cost Shift？A Review of the Evidence，”Milbank Quarterly 89 （2011），90-130。

77.Berenson et al.,"The Growing Power of Some Providers to Win Steep Payment Increases."

78.R.E.Santerre,"Health-Insurer Market Power:Theory and Evidence,"Encyclo-pedia of Health Economics (Burlington:Elsevier Science,2014),447-455.

79.Stacey McMorrow and John Holahan,"The Widespread Slowdown in Health Spending Growth" (Washington,D.C.:Urban Institute,June 20,2016),http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2016/rwjf429930.

80.Michelle Long et al.，“Trends in Employer-Sponsored Insurance Offer and Coverage Rates，1999-2014” （Menlo Park，Calif.，Kaiser Family Foundation，March 2016），5.小企业雇主的就业岗位提供率继续下降。见 Paul Fronstin，“Fewer Small Employers Offering Health Coverage；Large Employers Holding Steady，”Notes （Em-ployee Benefit Research Institute），July 2016。

81.Amitabh Chandra,Jonathan Holmes,and Jonathan Skinner,"Is This Time Different?The Slowdown in Health Care Spending,"Brookings Papers on Economic Activity (Fall 2013),261-302.

82.Henry J.Aaron,"How to Rescue Obamacare as Insurers Drop Out,"Washing-ton Post,August 19,2016.

83.Reed Abelson and Margot Sanger-Katz,"Obamacare Options?In Many Parts of Country,Only One Insurer Will Remain,"New York Times,August 19,2016;Simon E Haeder,David L.Weimer,and Dana B.Mukamel,"Secret Shoppers Find Access to Providers and Network Accuracy Lacking for Those in Marketplace and Commercial Plans,"Health Affairs 35 (2016),1160-1166.

84.1950年，美国医学会会员占医生中的73%，1989年下降到40%并继续下降，到2011年，只有15%的美国医生属于美国医学会。（这一比例不包括医学院学生和住院医师，他们不需要支付全部会费。）医生们并没有拒绝所有的集体组织。一些主要的专科协会—美国内科医师协会、美国外科医师协会和美国家庭医师协会—在最近几十年里有了显著的增长。专科协会的认证和医学继续教育计划可能使它们与职业发展更相关。关于美国医学会会员的减少，见Roger Collier，“American Medical Association Membership Woes Continue，”Canadian Medical As-sociation Journal 183 （August 9，2011），E713-14。

85.American Medical Association,Physician Characteristics and Distribution in the U.S.(Chicago,Ill.:AMA,2015),453.

86.Centers for Medicare and Medicaid Services,National Health Expenditure Ac-counts,"NHEGDP14," https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccounts Historical.html.

87.Robert J.Blendon et al.，American Public Opinion and Health Care （Washington，D.C.：CQ Press，2011），Table 2-5.另见Robert J.Blendon，John M.Benson，and Joa-chim O.Hero，“Public Trust in Physicians：U.S.Medicine in International Perspec-tive，”New England Journal of Medicine 371 （October 23，2014），1570-1572。

88.Abigail Zuger,"Dissatisfaction with Medical Practice,"New England Journal of Medicine 350 (January 1,2004),69-75.

89.Ibid.

90.Jack Hadley and Jean M.Mitchell,"The Growth of Managed Care and Changes in Physicians'Incomes,Autonomy,and Satisfaction,1991-1997,"International Jour-nal of Health Care Finance and Economics 2 (2002),37-50.

91.Zuger,"Dissatisfaction with Medical Practice";Hadley and Mitchell,"The Growth of Managed Care."

92.Kevin Grumbach et al.,"Primary Care Physicians'Experiences of Financial Incentives in Managed-care Systems," New England Journal of Medicine 339 (1998),1516-1522.

93.Phillip R.Kletke,David W.Emmons,and Kurt D.Gillis,"Current Trends in Physician Practice Arrangements:From Owners to Employees," JAMA 276 (August 21,1996),555-560.

94.关于这些变化的概述，见James C.Robinson，The Corporate Practice of Med-icine：Competition and Innovation in Health Care （Berkeley：University of California Press，1999）。

95.Lawton Robert Burns,Jeff C.Goldsmith,and Aditi Sen,"Horizontal and Verti-cal Integration of Physicians:A Tale of Two Tails,"Advances in Health Care Manage-ment 15 (2013),66,72.

96.Lawrence Casalino，“Physicians and Corporations：A Corporate Transforma-tion of American Medicine？” Journal of Health Politics，Policy and Law 29，no.4 （2004），869-883.另见Hai Fang and John A.Rizzo，“Has the Influence of Managed Care Waned？Evidence from the Market for Physician Services，”International Journal of Health Care Finance and Economics 10 （2010），85-103。

97.Uwe E.Reinhardt,"The Rise and Fall of the Physician Practice Management Industry,"Health Affairs 19,no.1 (January-February 2000),42-55;Timothy Lake et al.,"Something Old,Something New:Recent Developments in Hospital-Physician Relationships,"Health Services Research 38 (2003),471-488.

98.David N.Gans,"Has the Tide of Practice Acquisition Ebbed?"MGMA Connec-tion (January-February 2015),http://www.mgma.com/practice-resources/mgma-con-nection-plus/mgma-connection/2015/january-february-2015/oe-has-the-tide-of-practice-acquisition-ebbed.

99.American Medical Association,"New AMA Study Reveals Majority of Amer-ica's Physicians Still Work in Small Practices," July 15,2015,http://www.ama-assn.org/ama/pub/news/news/2015/2015-07-08-majority-americas-physicians-work-small-practices.

100.Robert M.Wachter and Derek Bell，“Renaissance of Hospital Generalists，”BMJ：British Medical Journal 344，no.7851 （April 7，2012），25-27；2015年的估值（来自医院医学学会），见Sara Royster，“Career Outlook：Hospitalist，” U.S.Bureau of Labor Statistics，July 2015，http：//www.bls.gov/careeroutlook/2015/youre-a-what/hospitalist.htm.

101.John D.Blum,Shawn R.Mathis,and Paul V.Voss,"The Hospital-Physician Relationship,"in Oxford Handbook of U.S.Health Law,ed.I.Glenn Cohen,Allison K.Hoffman,and William M.Sage (New York:Oxford University Press,2017),512-534.

102.Burns,Goldsmith,and Sen,"Horizontal and Vertical Integration of Physi-cians";AMA,"New AMA Study Reveals Majority of America's Physicians Still Work in Small Practices."

103.Burns,Goldsmith,and Sen,"Horizontal and Vertical Integration of Physi-cians."

104.Ibid.;Jeff Goldsmith,Nathan Kaufman,and Lawton Burns,"The Tangled Hos-pital-Physician Relationship," Health Affairs Blog,May 9,2016,http://healthaffairs.org/blog/2016/05/09/the-tangled-hospital-physician-relationship/.

105.Sage，“Antitrust Enforcement and the Future of Healthcare Competition，”606-636.联邦贸易委员会政策转变背后的政治因素，见Robert Kuttner，“Physi-cian-Operated Networks and the New Antitrust Guidelines，”New England Journal of Medicine 336 （January 30，1997），386-391。

106.Ann S.O'Malley,Amelia M.Bond,and Robert A.Berenson,"Rising Hospital Employment of Physicians:Better Quality,Higher Costs?"Issue Brief no.136 (Wash-ington,D.C.:Center for Studying Health System Change,August 2011);Austin B.Frakt,"The Downside of Merging Doctors and Hospitals,"New York Times,June 13,2016;Michael L.Barnett et al.,"Trends in Physician Referrals in the United States,1999-2009,"Archives of Internal Medicine 172 (2012),163-170.

107.Goldsmith,Kaufman,and Burns,"The Tangled Hospital-Physician Relation-ship."

108.Gregory C.Pope and John E.Schneider,"Trends in Physician Income,"Health Affairs 11 (1992),181-193;Carolyn K.Kane and H.Loeblich,"Physician Income:The Decade in Review," in Physician Socioeconomic Statistics 2003,ed.J.Wassenaar and S.Thran (Chicago:American Medical Association,2003),5-11;Ha T.Tu and Paul B.Ginsburg,"Losing Ground:Physician Income,1995-2003,"Tracking Report no.15 (Washington,D.C.:Center for Studying Health System Change,2006).

109.Seth A.Seabury,Anupam B.Jena,and Amitabh Chandra,"Trends in the Earnings of Health Care Professionals in the United States,1987-2010," JAMA 308 (November 28,2012),2083-2085.

110.Carol Peckham,"Medscape Physician Compensation Report," April 1,2016,http://www.medscape.com/features/slideshow/compensation/2016/public/over-view#page=2;U.S.Department of Labor,Bureau of Labor Statistics,"May 2015 Na-tional Occupational Employment and Wage Estimates" (Washington,D.C.),http://www.bls.gov/oes/current/oes_nat.htm#29-0000.

111.Sherry A.Glied,Stephanie Ma,and Ivanna Pearlstein,"Understanding Pay Differentials Among Health Professionals,Nonprofessionals,and Their Counterparts in Other Sectors,"Health Affairs 34,no.6 (2015),929-935.

112.John Bakija，Adam Cole，and Bradley T.Heim，“Jobs and Income Growth of Top Earners and the Causes of Changing Income Inequality：Evidence from U.S.Tax Return Data” （Williamstown，Mass.：Williams College；2010），Table 2.《纽约时报》的最新数据显示，收入前1%的人中有21.5%的医生。见 Jeffrey White et al.，“The Top 1 Percent：What Jobs Do They Have？”New York Times，January 16，2012，http：//www.nytimes.com/packages/htrnl/newsgraphics/2012/0115-one-percent-occupa-tions/index.html？ref=business。

113.专科医生和初级保健医生之间的区别，见 Bryan T.Vaughn et al.，“Can We Close the Income and Wealth Gap between Specialists and Primary Care Physicians？”Health Affairs 29 （May 2010），933-940；性别差异，见A.K.Boule and Jerry Jacobs，The Changing Face of Medicine：Women Doctors and the Evolution of Health Care in America （Ithaca，NY：Cornell University Press，2010）；专科医生和初级保健医生在收入方面的相对差异，见David M.Cutler and Dan P.Ly，“The （Paper）Work of Medicine：Understanding International Medical Costs，”Journal of Economic Perspec-tives 25 （2011），3-25。如果更普遍的模式适用，美国医疗行业内的收入不平等可能已经加剧：Chang Hwan Kim and Arthur Sakamoto，“The Rise of Intra-Occupational Wage Inequality in the United States，1983 to 2002，”American Sociological Review 73 （2008），129-157.

114.我用“社会均衡器”一词，只是指线上信息和社区以及直接面向消费者的广告减少了对医生的依赖，而不是指信息同样可靠。关于许多线上信息的可疑价值，见Austin Frakt，“Using the Web or an App Instead of Seeing a Doctor？Caution Is Advised，”New York Times，July 11，2016。

115.David Mechanic,"The Managed Care Backlash:Perceptions and Rhetoric in Health Care Policy and the Potential for Health Care Reform,"Milbank Quarterly 79 (2001),38.

116.David H.Autor,"Why Are There Still So Many Jobs?The History and Future of Workplace Automation," Journal of Economic Perspectives 29 (2015),3-30;Erik Brynjolfsson and Andrew McAfee,The Second Machine Age (New York:W.W.Nor-ton,2014).

117.关于最近的评论，见 E.Ray Dorsey and Eric J.Topol，“State of Telehealth，”New England Journal of Medicine 375 （July 14，2016），154-161。

118.对初级保健举措的历史的详细论述，见Somers，“And Who Shall Be the Gatekeeper？”。

119.Einer Elhauge,The Fragmentation of U.S.Health Care:Causes and Solutions (New York:Oxford University Press,2010);Paul Starr,"Law and the Fog of Health Care,"Saint Louis University Journal of Health Law and Policy 6 (2013),213-228.

120.Cutler and Ly,"The (Paper)Work of Medicine";Steffie Woolhandler,Terry Campbell,and David U.Himmelstein,"Costs of Health Care Administration in the U.S.and Canada,"New England Journal of Medicine 349 (2003),768-775.

121.Anderson et al.,"It's the Prices,Stupid";Uwe Reinhardt,"Divide Et Impera:Protecting the Growth of Health Care Incomes (Costs),"Health Economics 21 (2012),41-54.

122.Cooper et al.,"The Price Ain't Right?";Steven Brill,"Bitter Pill:Why Medical Bills Are Killing Us,"Time Magazine,February 20,2013.

123.Reinhardt,"Divide Et Impera,"41.

124.Paul Grundy et al.,"The Multi-Stakeholder Movement for Primary Care Re-newal and Reform,"Health Affairs 29 (2010),791-798.

125.Calvin Sia et al.,"History of the Medical Home Concept,"Pediatrics 113 (2004),1473-1478.

126."Joint Principles of the Patient-Centered Medical Home,"March 2007,http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCM-HJoint.pdf;"Defining the PCMH," U.S.Department of Health and Human Services,Agency for Healthcare Research and Quality,https://www.pcmh.ahrq.gov/page/de-fining-pcmh.

127.Samuel T.Edwards et al.,"Patient-Centered Medical Home Initiatives Ex-panded in 2009-13:Providers,Patients,and Payment Incentives Increased," Health Affairs 33 (2014),1823-1831.

128.Barnett et al.,"Trends in Physician Referrals in the United States,1999-2009."

129.对其中许多观点的支持性批判，见Robert Berenson and Rachel Burton，“How Solid Is the Primary Care Foundation of the Medical Home？” Health Affairs Blog，March 25，2016，http：//healthaffairs.org/blog/2016/03/25/how-solid-is-the-pri-mary-care-foundation-of-the-medical-home/.

130.Mark McClellan,Frank McStay,and Robert Saunders,"The Roadmap to Phy-sician Payment Reform:What It Will Take for All Clinicians to Succeed Under MAC-RA,"Health Affairs Blog,August 30,2016.

131."Pay-for-Performance,"Health Policy Brief (Health Affairs),October 11,2012;Aaron E.Carroll,"The Problem with'Pay for Performance'in Medicine,"New York Times,July 28,2014.

132.质量的衡量标准会被典型地分为三类—结构、过程和结果。更小型的诊所和低收入地区的医疗机构在满足前两类要求方面处于不利地位。此外，低收入病人往往有多种问题，会导致更糟糕的结果，而风险调整措施可能只能不完全地解决这个问题。

133.Lydia Saad,"Restaurants Again Voted Most Popular U.S.Industry," Gallup,August 15,2016,http://www.gallup.com/poll/194570/restaurants-again-voted-pop-ular-industry.aspx?utm_source=alert&utm_medium=email&utm_content=more-link&utm_campaign=syndication.