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.
A Learning a Day 