Licensure Supply of Medical Services

Physician licensure and quality: Part IIX

In The Social Transformation of American Medicine, author Paul Starr analyzes the development of modern American medicine. A large portion of the book looks at the roots of physician licensure. His analysis dates back to the colonial era. Some important turning points in the history of physician licensure before the twentieth century are:

  • In the 17th century, “[colonial] legislatures would now and then bestow licenses on worthy doctors, but the acts themselves indicate that these men had already been in practice for years.”
  • “An early Massachusetts law…states that no one ought to engage in healing ‘without the advice and consent of such as are skillful in the same Art, (if such may be had) or at least some of the wisest and gravest then present.'”
  • In 1760, New York City passed the first law which called for the examining and licensing of prospective doctors and placed a fined on unlicensed physicians. Unlike present day medical societies, licensure authority rested with city officials.
  • “In 1763 physicians in Norwich, Connecticut, requested their colonial legislature ‘to Distinguish between the Honest and Ingenious Physician and the Quack or Empirical Pretender’ by allowing doctors to found societies with licensing power. Both these bids for authority were rejected.”
  • After independence, medical societies were organized in many states, and legislatures often extended them licensing powers. Since there was no set standard for education or achievement in order to obtain a license, the medical societies were largely ineffective in restricting physician supply. The societies faced a fundamental problem. If high standards for membership were implemented,the group size would be small and the society would not be able to outlaw ‘quacks’ or stop price competition; lowering standards and admitting more practitioners would weaken the society’s position that the organization’s goal was to maintain high quality standards.

Starr distinguishes between ‘hostile’ and ‘friendly’ licensing. The ‘hostile’ form occurs when government officials are placed in charge of physician licensure; the ‘friendly version manifests itself when licensing is self-regulated within a profession. While friendly licensing did appear in NYC in the late eighteenth century, it only manifested itself on a large scale in the late nineteenth century.

  • In 1877, Illinois passed a law empowering a state board of medical examiners to reject diplomas from disreputable schools. “Under the law, all doctors had to register. Those with degrees from approved schools were licensed, while others had to be examined. Of 3,600 nongraduates practicing in Illinois in 1988, 1,400 were reported to have left the state within a year. Within a decade, three thousand practitioners were said to have been put of of business.”
  • In 1888 in the Dent v. West Virginia case, the U.S. Supreme Court upheld a West Virginia law which required practitioners “…to hold a degree from a reputable medical college, pass an examination, or prove that he had been in practice in the state for the previous ten years.”
  • In the 1898 the Hawker v. New York case extended the grounds for denying a medical licensing. The Supreme Court decision noted that “character is as important a qualification as knowledge.”
  • In 1901, the Missouri board of health was empowered to act as a board of medical examiners.

Despite increased control of physician licensure, the American Medical Association still was not successful in restricting the supply of doctors, because as licensing requirements increased, the number of medical schools awarding physicians licenses increased just as rapidly. Thus, not until the Flexner report—when the AMA gained control over medical education standards in the United States—were physicians able to truly restrict medical practitioner entrance and create economic rents for existing providers.