The Flexner Report – American Healthcare Chronicles

I recently started building products focused on healthcare affordability in the US. As I was ramping up on a new space, the biggest question that sparked my curiosity was: how did we get here? This question is the inspiration for this weekly series chronicling the decisions, accidents, and breakthroughs that built the US healthcare system.

Across the last few posts, one institution kept appearing as the immovable object in American healthcare — the American Medical Association. They killed Truman’s universal coverage plan with a fabricated Lenin quote. They tried to shut down Kaiser’s shipyard health plan by barring his doctors from existing hospitals. They called both “socialized medicine.”

To understand how a professional association accumulated that kind of power, we need to go back to 1910. To a report written by a man who had never treated a single patient in his life.

In the early 1900s, American medicine was chaotic. Medical schools resembled today’s for-profit colleges. There were no common standards for curriculum or matriculation. Many didn’t require students to have a high school diploma, and only the most elite programs took more than a year to complete. In 1904, there were 160 medical schools. The word “quack” was in common use.

The AMA had been pushing for standardization for years — but their conclusions carried the smell of self-interest. They needed an outside voice.

They found him in Abraham Flexner. He was not a doctor. He held a Bachelor of Arts degree and ran a for-profit school in Louisville, Kentucky. The Carnegie Foundation hired him to survey every medical school in North America. He visited all 155.

What he found was damning — students with no clinical training, schools admitting anyone who could pay fees, facilities barely functional. His 1910 report called for a complete restructuring: all schools connected to universities, two years of basic science followed by two years of clinical training, rigorous admissions standards. The model he described is still the foundation of American medical education today.

The results were swift. By 1920 there were 85 medical schools — down from 160. By 1935, more than half had merged or closed. The survivors were stronger, better funded, university-affiliated.

But something else happened alongside the quality improvement.

Fewer schools meant fewer doctors. Fewer doctors meant less competition and higher fees. Standardized licensing, controlled by state boards the AMA influenced, gave the profession a gatekeeper it had never had before. The reform that cleaned up American medicine simultaneously handed the AMA extraordinary control over who could enter it.

The report had other unintended consequences. For example, the cost of the report fell disproportionately on Black Americans as well. In 1910, there were seven historically Black medical colleges. They existed because mainstream schools almost universally refused to admit Black students. These institutions trained the doctors who served Black communities — communities that had no other access to care.

Flexner recommended closing five of them, saying only Howard University in Washington DC and Meharry Medical College in Nashville were worth developing. Five schools closed. Estimates suggest those institutions might have trained between 30,000 and 35,000 Black physicians over the following century. No new Black medical school opened between 1920 and 1987, when Morehouse School of Medicine opened in Atlanta. The AMA’s own local chapters prohibited Black doctors from membership well into the late 1960s.

This is what makes the story of American Healthcare fascinating. The Flexner Report genuinely improved American medical education. It built the scientific foundation that made the US a world leader in research and innovation — the breakthroughs in cancer treatment, vaccines, and medical technology that appear later in this series all rest on the infrastructure it helped create.

And it concentrated power, reduced access, and closed the schools serving communities the mainstream profession had no interest in serving.

The AMA that killed Truman’s plan, that attacked Kaiser, that shaped American healthcare policy for most of the twentieth century — that institution’s authority runs directly through 1910. Through a report written by a schoolteacher from Louisville, funded by Carnegie, embraced by an establishment that understood that controlling the supply of doctors was the foundation of everything else.

Paul Starr’s quote “The dream of reason did not take power into account” is an apt place to end today’s story.

Coastal redwoods

Coastal redwoods are the tallest tree species on earth. They exist only within a mile of the California coast, sustained by fog — drawing water directly from the air to feed themselves.

But the most intriguing thing about these majestic giants isn’t their height. A four-hundred-foot tall redwood has roots only eight to twelve feet deep. What keeps them standing is that those roots spread up to two hundred feet outward — intertwining with the roots of neighboring trees, connected through mycelium, sharing nutrients, holding each other steady, supporting the younger ones still growing.

Their survival isn’t a solo act. It takes a village.

For a species so rare and so majestic, it’s a beautiful reminder of what it actually takes to survive on this planet.

Shift the momentum

Midway through Game 4 of the NBA Finals, the San Antonio Spurs had the biggest lead in NBA Finals history — twenty-nine points. They ended up losing by one.

One word explains most of it: momentum.

I think about it every time something disrupts my routine. A good run of exercising, eating well, staying on track — and then travel, or something else, gets in the way.

Momentum is so easy to lose. And yet so powerful when you have it, because every move builds on the previous one.

It’s an ally when you can use it. An archenemy when you lose it.

The helpful reframe for me is that when the odds feel difficult, you don’t have to worry about the end. You just have to shift the momentum. Focus on the next thing that builds it, then the next. Keep going.

Just like the Knicks did.

iPhone birth control

Yesterday, I shared Noah Smith’s observation that fifteen years ago, the internet was an escape from the real world — and now the real world is an escape from the internet.

Smith recently shared a study that puts hard numbers behind that idea.

Researchers at NBER used a clever natural experiment: the iPhone launched in 2007 exclusively on AT&T through early 2011. That carrier exclusivity created geographic variation — some areas had coverage, others didn’t — allowing them to isolate the smartphone’s effect on birth rates.

The results are striking. iPhone access reduced births by 4.5–8% among 15–19 year olds and 3.2–6.6% among 20–24 year olds. Overall, the diffusion of the iPhone explains 33–52% of the entire decline in the U.S. fertility rate since 2007 among women aged 15–44.

The mechanism the researchers point to: less in-person interaction, more pornography use, less sexual frequency.

Sadly, it all makes intuitive sense. And birth control is likely just the tip of the iceberg.

And while it is easy to point to everyone else, the first place to examine at is our own phone habits.

488-40-6969A – American Healthcare Chronicles

I recently started building products focused on healthcare affordability in the US. As I was ramping up on a new space, the biggest question that sparked my curiosity was: how did we get here? This question is the inspiration for this weekly series chronicling the decisions, accidents, and breakthroughs that built the US healthcare system.

In November 1945, seven months into his presidency, Harry Truman sent a message to Congress that would define the next two decades of his life.He had identified a problem the employer-sponsored system couldn’t solve. That system worked well for people who were employed. But the elderly had retired. The very poor had never had employer coverage. And the middle class had no protection against the financial devastation of serious illness.

Truman proposed a solution: a national health insurance program, funded through payroll taxes, open to all Americans. A survey taken shortly after found 59% of Americans who knew about the plan supported it.

The American Medical Association saw it differently and launched one of the most aggressive lobbying campaigns in American political history. They hired a public relations firm, used the phrase “socialized medicine,” and distributed pamphlets to doctors’ waiting rooms across the country

. They even circulated a quote attributed to Soviet leader Lenin calling socialized medicine “the keystone to the arch of the Socialist State.” This was fabricated. But the campaign worked anyway. Public support collapsed from 59% to 24% in five years. Legislators across the aisle were moved by the same fears the AMA had carefully cultivated. Truman’s plan died in Congress.

He later wrote: “I have had some bitter disappointments as President, but one that has troubled me most has been the failure to defeat organized opposition to a national compulsory health insurance program.”

Twenty years passed with the problem remaining unsolved.

By 1963, the gap was stark. While 75% of Americans under 65 had hospital insurance, only 56% of those over 65 did. One in three elderly Americans lived in poverty.

The employer-based system had a blind spot built in from the beginning. It worked for people who were working. The moment you retired, you were on your own.

The bill finally went through in1965 with support from members of both parties who had watched the gap go unfilled for two decades. But it required a critical compromise: physicians and insurers retained control over their own fees. No price controls. This was the concession that got the medical establishment to stand down.

And it quietly planted the seeds of the cost explosion that followed.

In a wonderful twist to the story, President Lyndon B Johnson chose to sign the bill at Independence, Missouri instead of the White House. He explained that he considered President Truman “the real daddy of Medicare” and handed him and his wife Bess the first two Medicare cards ever issued.

Truman was 81. His card number was 488-40-6969A. He called it “a profound personal experience.”

The impact was immediate. Before Medicare, roughly half of older Americans had no health insurance. After its launch, coverage became nearly universal. Nearly 20 million people enrolled in the first three years. Elderly poverty fell from 29% to 12% over the following two decades. Medicare’s rollout also helped enforce the Civil Rights Act, driving hospital desegregation across the country.

Medicaid, passed in the same bill, extended coverage to low-income Americans. Today it covers more than 71 million people.

Within a decade, Medicare had become one of the most fiercely defended programs in Washington — protected by legislators on both sides who had seen what it meant to the people in their districts.

But the compromise that got it passed — no price controls, physicians and insurers setting their own fees — meant the federal government had become a massive paying customer with no ability to negotiate. Medicare would pay whatever was charged.

The program that answered the question of “what happens when you leave your job?” had created a new one: What happens when costs have no ceiling?

When typing is better than talking

I’m a heavy user of voice-to-text. It’s a key part of my workflow, and it improves my productivity — but only about sixty percent of the time. Lower than I expected when I first started using it.

Here’s what I’ve realized. Voice-to-text improves the efficiency with which I get an idea down. But that’s only a gain when the bottleneck is the speed of capture. A lot of the time, the bottleneck is actually the thinking itself — and the act of typing, with its slight slowness, gives me the time to process. In those moments, voice offers no efficiency gain.

This points to something broader about any system or tool. An improvement only counts if it’s an improvement to the actual constraint.

Optimize anything else and it doesn’t really matter.