The most widely circulating critiques of American healthcare tend to emphasize the challenges and opportunities facing singular actors, especially patients and physicians. Yet, to understand the historical and political development of American medicine, and to understand the machinations that truly drive the healthcare industry in which it operates, one needs to tarry with the institutions that have served, for better or worse, as medicine’s nodal centers of power. Such analysis forces us to work through a sustained paradox—hypocrisy, even—lodged in the fact that medicine’s lofty claims about itself do not always track with the actions of its most formidable institutions. Indeed, these institutions too often actively militate against the interests of patients and populations. As their titles starkly suggest, the two books under review here each diagnose an important part of what afflicts American healthcare. Both, in their own way, leave us wondering if American healthcare institutions, and the professionals who comprise them, are capable of serving as a positive force in addressing the most pressing problems.

In Disorder: A History of Reform, Reaction, and Money in American Medicine, Peter Swenson immerses readers in the late nineteenth and early twentieth centuries to rethink the role that the American Medical Association (AMA) has played in the larger development of American healthcare. Throughout the book readers are aware that Swenson is challenging aspects of sociologist Paul Starr’s (1982) The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry, with its widely accepted claim that the history of American medicine has been shaped primarily by physicians’ systematic and unrelenting pursuit of professional autonomy and mostly self-serving power. According to Swenson, Starr’s otherwise magisterial book misses the internecine struggles within the AMA from about the 1890s until about 1920, as reformers aligned with the spirit of American progressive reformers generally. During this period, Swenson ably demonstrates that AMA progressives sought to clean up the House of Medicine through actions such as limiting the influence on the profession of cynical purveyors of nostrums lacking scientific validity; exposing a pay-to-play medical education system that trained barely competent physicians; and championing public health, which was too often seen as a threat to medicine, which benefited financially from disease.

By the 1920s, however, these progressive pursuits had been all but eliminated from the AMA, with a purging of progressive reformers leading to a conservative takeover of the AMA that eventually put the organization directly into the hands of the nefarious interests to which scholars have long pointed. Among the scandalous entanglements that we now understand as unacceptable conflicts of interest were relationships with the tobacco and pharmaceutical industries, the latter of which continued well into the twenty-first century with the opioid epidemic, and which some regard as continuing to this day, albeit in new forms. Swenson’s recasting of AMA history, supported by an impressive array of scholarly evidence, provides readers with new and more politically nuanced perspectives with which to think about the AMA and organizations like it.

Swenson’s fresh take on the AMA should prove helpful to scholars interested in considering whether the AMA could play a more productive role in the coming decade of healthcare policy than it did during the mid-twentieth century. Whether what Swenson views as a “new medical progressivism” (chap. 15) can be harnessed for such ends remains to be seen. Certainly, those who know (or think they know) the AMA’s track record within the broader context of American healthcare reform will need to be convinced.

If Swenson instills in readers a small hope that organized medicine might be positioned to play a transformative role in addressing the maladies facing American medicine, Laura Katz Olson’s Ethically Challenged: Private Equity Storms U.S. Health Care returns readers to a thoroughgoing, if not-quite-healthy, skepticism. Where Swenson leaves readers with a picture of a new wave of principled—even progressive—physicians challenging the conservative wave that entwined medicine with corrosive business interests and beyond, Olson makes clear that private equity’s relentless commodification of almost every corner of American healthcare makes it increasingly hard for healthcare institutions to lay claim to putting patients first.

Readers will be relieved to find that Olson does the hard work of unpacking the complicated world of private equity (thankfully, the book also contains a handy glossary of technical terms). Olson takes the time to explain the many crafty tools in the private equity toolbox, beginning with leveraged buyouts, but also a sweeping range of investment and debt-management tactics to stimulate short-term cash flow. The main thrust of private equity, in Olson’s telling, is to pick at the bones of struggling businesses, taking what they want from them before leaving them to die.

Only after laying this groundwork does Olson hone in on healthcare, specifically. As we would expect, Olson’s focus on healthcare emphasizes not only the huge market opportunities healthcare presents in the US, but moral outrage at private equity’s tendency to treat healthcare as just another industry to be exploited, with no special concern for the impact that such financial tactics have on lives. To show private equity’s reach, subsequent chapters explore a wide array of topics, with Olson starkly declaring that “nowadays acquisitions and mergers are skyrocketing in all niches” (p. 127). Perhaps the most disturbing aspects of Olson’s accounting of private equity’s pilfering of American healthcare are her detailed discussions of equity’s rapacious takeover of areas in which patients are particularly vulnerable, such as the largely for-profit home healthcare industry, as well as equity’s deleterious effects on specific disease treatments, from addiction, to autism, to eating disorders.

The sweeping examination Olson provides of private equity’s inroads into every corner of the massive American healthcare industry provides a sense of just how far equity’s reach has extended. Depressingly, though honestly, Olson does not offer any reason for us to be optimistic that there are limits to this reach. As she explains in the closing pages of the book, state and federal action will be required if the malignant forces she describes are to be curbed. But given the degree of regulatory and legislative capture that private equity has already accomplished, the reader is given little reason to hope that a progressive democratic politics will arise to serve as a counterweight. Even more concerning is that there is little reason to believe that any lessons were learned from the COVID-19 pandemic, which actually provided investment opportunities for private equity to not only prey upon struggling healthcare practices, but to leverage federal relief funding for shrewd financial gains.

Taken together, Swenson and Olson’s books give us different but similarly stark examples of why American healthcare policy continues to frustrate, and especially why progressive reform that puts patients and populations first is so elusive. Critics of American healthcare often fail to train their analyses on the actual forces that ultimately shape American health policy, which are lodged in the institutional underbellies of little-understood entities. While the inner workings of the organizations such as the AMA—the subject of Swenson’s book—are not something most Americans know much about, Olson shows that private equity is actively shrouded in secrecy, and hence extremely difficult to study, even for scholars who admirably dedicate themselves to the cause.

Transparency—or the lack thereof—is therefore a unifying theme across both books, whether we are concerned with shadowy advertising and consultancy arrangements, nondisclosure agreements, or other tools of opacity. Even more than transparency, however, readers will be struck by the question of animating values. For Swenson, the question is whether the AMA of the future, in a reversal of the last hundred years of its history, will transform itself to become a force for good within the larger field of American healthcare, especially by making public health and preventive care a priority. Olson’s question is whether private equity’s singular focus on profits can be reined in, especially through federal policy. While the fate of the AMA will be determined in a primarily endogenous manner, as a function of internal deliberations within the body’s House of Delegates, Olson is under no illusion that only congressional action can prevent private equity’s assault on American healthcare. Private equity is, after all, “ethically challenged.”

Shorn of the sentimental veneer that allows medical professionals to recite oaths claiming that “doing no harm” is their central concern, these books remind us, in important ways, that medicine is at base just another industry ripe for the picking to those principally interested in reaping profits. There is just too much stakeholder power and investment potential in American medicine to sustain the fiction that medicine somehow operates outside of the vagaries of American capitalism, or that it is a special kind of commodity. Like so many other challenges in American healthcare, the only solution appears to be a revitalized progressive politics—both within organizations and beyond—to reconfigure American healthcare institutions so that they meaningfully operate in the public interest. And yet, few readers are likely to be sanguine about the prospects that such a politics will arise any time soon.