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The Flexner Report’s Stranglehold on Health Care

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November 19, 2009 – Comments (4)

Congressman Ron Paul recently gave a speech on the House floor covering the topic of health care. In it he brought up the Flexner Report, an item that few individuals have even heard about that is worthy of much more attention than it currently receives.

“A lot of problems were created in 20th century as a consequence the Flexner Report (1910), which was financed by the Carnegie Foundation and strongly supported by the AMA. Many medical schools were closed and the number of doctors was drastically reduced.” — Ron Paul; September 24, 2009

The seeds of the Flexner Report were planted in 1908 when the Carnegie Foundation for the Advancement of Teaching commissioned Abraham Flexner, a high school principle, to research and report on medical schools in the U.S. Flexner himself was not involved in the medical industry, but after being asked to take on the report he researched and grew fond of the medical systems in England, France, and Germany.

In the report, which was officially published in 1910, Flexner called homeopathic schools “a striking demonstration of the incompatibility of science and dogma.” What’s curious is that Flexner points out that between 1900 and 1909 homeopathic schools decreased from 22 to 15 and students within the schools decreased from 1,909 to 1,009. Flexner uses these figures to conclude that “the rise of legal standard must inevitably affect homeopathic practitioners.” In short, even with the marketplace whittling out the unproductive and unsustainable homeopathic colleges (or any colleges, for that matter) that Flexner clearly did not appreciate, he still advocated increased government intervention to further clear out homeopathic schools.

Flexner believed the problems in medicine were primarily because there were too many doctors and medical colleges. “The country needs fewer and better doctors; and…the way to get them better is to produce fewer.” The flaws of Flexner’s arguments and his general report is that he may indeed have made some noticable observations, but he did not consider the economic consequences of increased government intervention, a centralized medical system in the hands of the American Medical Assossiation (AMA), and the impact of fewer doctors and medical schools.

Basic economic common sense tells us that when you forcibly remove one product without subsequently lowering demand, you will increase the price of that product. Less supply without less demand means higher prices. The homeopathic schools that Flexner so strongly criticized may have lacked in some areas of educational standards compared to more traditional health schools, but they provided a key element of competition for allopathic medicine and an essential choice for individuals who needed health care.

Basic economics also tells us that weak products and services are bound to fail to the competition due to inefficiency and poor judgment. As I previously mentioned, Flexner’s own research displayed that homeopathic schools were struggling to stay open and maintain steady attendance. Their services had difficulty competing in some cases, and those schools (or services) disappeared or were in the process of failing.

The publishing of the Flexner Report in 1910 led to many educational reforms. Among Flexner’s final proposals included extending years spent in health education (two years in undergraduate collegiate studies and four years in medical school), increasing the caliber of medical schools to universities, expanding government involvement in medicine, decreasing total graduates to 3,500 from 4,500, and bringing the total amount of medical schools in the U.S. from 150 to roughly 31. In short, Flexner proposed a medical system driven not by the free market and individuals, but a manipulated system molded by some of the wealthiest men and foundations in the world. In fact, the Rockefeller Foundation donated large sums of money to schools who followed the model recommended by the Flexner Report.

One of the unfortunate impacts the Flexner Report had on medical education was the shut-down of many schools geared toward disadvantaged rural areas, African-Americans, and women. Because of mandated school time regulated by the AMA and state governments, only those wealthy enough to afford at least six years of college had a chance at becoming a licensed doctor. This essentially limited the market for prospective doctors to wealthy white males. (All but two African-American medical colleges were closed.)

The flaw with the Flexner Report is the same flaw that has brought us to today’s broken medical system. When a product is forcefully limited to be provided by a certain central group (in this case the AMA), it will reduce choice and competition. Choice and competition in a free marketplace are what drive businesses to become more efficient and productive, which provides the greatest possible benefits to individuals who are able to freely buy and sell in the market. A strong, sustainable system built for individuals cannot come from a manipulative central source, it must come from the demands and choices of the people whom it is intended to help.

Government regulatory standards do not necessarily serve the individual as many people believe. In the case of medical care, the Flexner Report recognized many flaws with education that the free market was already weeding out on its own. Rather than allow people and communities to make their own choices with doctors, medicine, and education, it was all placed in the hands of the AMA and state governments, thus limiting the supply. This resulted in less doctors, more expensive education, and decreased access to medical care.

A central system concentrates power into the hands of a select few individuals, groups, and organizations who have the means to control that respective market. A free market divides that power among individuals who have the ability to make their own decisions themselves and through their communities.

Concentrated control, as proposed and implemented in the Flexner Report, is the direct cause of the majority of problems with health care today. The solution does not lie with more government intervention and centralized power, but rather with increased individual freedom. The answer is not centralized power in government, but centralized power within ourselves.

FreedomChatter.com

4 Comments – Post Your Own

#1) On November 19, 2009 at 8:11 AM, TMFBent (99.83) wrote:

The problem here has nothing to do with a 100 year old report or a lack of competition. The problem is that medical care has separated the consumers from the costs. As you like to put it, David, basic economics tells you that demand and price are inextricably linked. What happens when you make something cheaper than it otherwise should be is that demand skyrockets.

The problem is very simple, but the solution is not. And not because of any lack of freedom or competition. It's because everyone wants the best healthare money can buy -- but they don't want to pay the cost of that healthcare.

Until we realize that "rationing" is inevitable, it will never be fixed. We are all subject to "rationing" every day. We do the rationing for ourselves when we go to the grocery store or the car lot. But if we didn't see the bill at those places, and someone else paid it, I guarantee you no one would spend any time trying to choose between the ground chuck and the ground siloin. They'd head straight for the filets and load up the Bently's trunk.

The problem with healthcare, and with the healthcare debate, is that no one wants to admit this truth. They seek other places to put the blame (AMA, insurance companies, rationing desk jockeys, greedy pharma execs).

The baseline offender, however, is the person staring back in the mirror who will spend anything to feel immortal -- so long as someone else is doing the paying.

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#2) On November 19, 2009 at 12:12 PM, Gemini846 (83.59) wrote:

The argument Bent is that if there were more caregivers then more care would be availible.

Take the recent expansion in P.A. programs. This is the market trying desperatley to clean up the need for caregivers without 10-12 years of school.

More, cheeper, base level services that most people can afford and the market will be able to self ration.

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#3) On November 19, 2009 at 8:28 PM, feld10 (< 20) wrote:

Both Ron Paul and the blogger have mis-represented one of the most important documents in the history of American medicine - the Flexner Report.  The inaccuracies are too numerous to count; however, I would point out several.  First, Flexner did not focus on "homeopathic" medical schools - he was equally concerned with the inadequacies he found in America's allopathic medical schools.  His true target was the "proprietary" (for profit) medical schools that existed before 1910 because they did not provide their students with a scientific underpinning nor were the students allowed to actually touch patients.  The schools he held out as being models for the future of American medicine were those found in Europe and in America (eg. Johns Hopkins) which required training in the basic science of medicine as well as hands-on experience with patients during the clinical years.  It is also unfair to characterize Flexner's work as suggesting that only wealthy white males should attend medical school.  In fact, Flexner points out that only schools with a financial underpinning should undertake medical education and thus a medical education should be within the reach of anyone.  The number of medical schools in the u.S. did not decrease immediately after the publication of the report - and never decreased below a total of 60.  More importantly, within a short period of time the many proprietary schools that were closed were replaced by state or county-supported medical schools that were far more affordable than the proprietary and for-profit medical schools. It was not until the last decade that we have faced a critical shortage of doctors in the U.S.  Lastly, the author obfuscates the truth when they suggest that the Flexner Report led to a takeover of American education by the AMA.  The AMA has no authority over any American medical school - that authority is exclusively in the hands of regional educational oversight groups such as the LCME and the American College of Graduate Medical Education (ACGME) at the national level.  Finally, the blogger suggests that there should be no regulation of medical education.  Perhaps they also believe that there should not be national standards for airline pilots, accountants or pharmaceutical manufacturers and that the occurrence of bad outcomes will control the marketplace.  For the reader that is truly interested in medical education in America, I would suggest they read Flexner's Report or the most recent report on American medical schools and the challenges they face entitled: "Pursuing Excellence in Health Care: Preserving America's Academic Medical Centers."

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#4) On November 19, 2009 at 9:39 PM, devoish (99.06) wrote:

It is relevant that US life expectancys went from just under 50 in 1910 to just under 70 by 1940 as a direct result of the accreditation standards bringing scientific advances to Dr's and patients. Something that was not happening prior to Flexners report and the formation of the AMA.

From Melissa Thomasson as published on eh.net. It is a nice short history of how healthcare/insurance got from 1913 to today.

According to Flexner, the current methods of medical education had "... resulted in enormous over-production at a low level, and that, whatever the justification in the past, the present situation... can be more effectively met by a reduced output of well trained men than by further inflation with an inferior product" (Flexner, p. 16). Flexner argued for stricter entrance requirements, better facilities, higher fees, and tougher standards. Following the publication of the Flexner Report, the number of medical schools in the United States dropped from 131 in 1910 to 95 in 1915. By 1922, the number of medical schools in the U.S. had fallen even further to 81 (Journal of the American Medical Association, August 12, 1922, p. 633). These increased requirements for physician licensure, education and the accreditation of medical schools restricted physician supply, putting upward pressure on the costs of physicians' services.2

Note #2 reads:2  These changes may also have increased physician quality, thus leading to an increase in demand for physicians' services that put additional pressure on prices.

It is relevant that US life expectancys went from just under 50 in 1910 to just under 70 by 1940 as a direct result of the accreditation standards bringing scientific advances to Dr's and patients. Something that was not happening prior to Flexners report and the formation of the AMA.

 Following the publication of the Flexner Report, the number of medical schools in the United States dropped from 131 in 1910 to 95 in 1915. By 1922, the number of medical schools in the U.S. had fallen even further to 81 (Journal of the American Medical Association, August 12, 1922, p. 633). These increased requirements for physician licensure, education and the accreditation of medical schools restricted physician supply, putting upward pressure on the costs of physicians' services.2

After Flexner's report, a further movement towards standardization and accreditation came in 1913, when the American College of Surgeons (ACS) was founded. Would-be members of the ACS had to meet strict standards. For a hospital to gain the accreditation of the ACS, it had to meet a set of standards relating to the staff, records, and diagnostic and therapeutic facilities available. Of 692 large hospitals examined in 1918, only 13 percent were approved. By 1932, 93 percent of the 1,600 hospitals examined met ACS requirements (Shyrock 1979, p. 348).

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