Saturday, March 18, 2023

Guian A. McKee's "Hospital City, Health Care Nation"

Guian A. McKee is Associate Professor of Presidential Studies, Miller Center of Public Affairs, University of Virginia, and author of The Problem of Jobs: Liberalism, Race, and Deindustrialization in Philadelphia.

He applied the "Page 99 Test" to his new book, Hospital City, Health Care Nation: Race, Capital, and the Costs of American Health Care, and reported the following:
Page 99 of my book, Hospital City, Health Care Nation: Race, Capital, and the Costs of American Health Care, captures an important moment in the overall narrative. It describes the complex 1969 negotiations between leaders of an African American community organization and Johns Hopkins Hospital administrators over the establishment of a community-based health care organization in the East Baltimore neighborhoods surrounding the hospital. These discussions took place within the context of the social movements of the 1960s generally and the urban rebellions of April 1968 specifically – a moment of high tension in Baltimore and around the U.S. They also followed the recent implementation of the federal Medicare and Medicaid programs, the latter of which had experienced a troubled rollout, but which provided an important source of funding for the new program. As a result, the negotiations involved profound questions about power and financing that determined who would pay for the new health program and by whom it would be controlled.

Interestingly, the first line of page 99 concludes a comparison on the previous page to another experimental Hopkins health program in the new suburban city of Columbia, Maryland. There, Johns Hopkins had a far easier task in arranging financing because of the widespread availability of private health insurance, which offered a revenue stream for the suburban program, and the presence of corporate investment capital ready to finance its health facilities. Neither of these conditions applied in the low-income neighborhoods of East Baltimore.

While the Page 99 Test effectively captures several key themes of Hospital City, Health Care Nation, it also misses critical components of the book. It does an excellent job of highlighting two things. First, it captures the deep tensions that characterized the relationship between Johns Hopkins and the neighboring African American community, rooted in experiences of sometimes discriminatory care at the hospital, in the low wage labor that many neighborhood residents supplied for Hopkins, and above all, in an urban renewal project a decade earlier that cleared a large amount of housing but did not ultimately supply new apartments that had been promised for displaced residents (a story that is recounted in chapter 2 of the book). Second, it effectively highlights how the financing of health care in the United States has contributed to deep disparities in access to quality health care – the goal of the East Baltimore project – and in health outcomes. Although page 99 itself doesn’t make this explicit, those disparate outcomes fall heavily along lines of race and class. In this sense, the page 99 test provides a snapshot of the processes that have created racial health disparities in the United States.

Hospital City, Health Care Nation, however, is more than just a local history of Baltimore and Johns Hopkins. It moves across scales of local, regional, state, and federal to retell the story of the U.S. health care system by focusing on the economic weight and political power of hospitals and large health systems. Specifically, the book shows that this economic importance is rooted in the high costs of the U.S. health care system, which play out in both the creation of jobs and the provision of care in every community around the country. These costs and what they represent, I argue, are central to why the system has been so hard to reform, and why its inefficiencies and irrationalities persist to the present. This is examined in chapters about national debates over health care policy in the U.S, which Hospital City, Health Care Nation in turn relates back to the local context of Baltimore. As useful as the Page 99 Test is in capturing the community and racial dimensions of such relationships, it does not give the reader a sense of this larger structure and argument.
Learn more about Hospital City, Health Care Nation at the University of Pennsylvania Press website and on a book page on the website of the University of Virginia’s Miller Center of Public Affairs.

--Marshal Zeringue