Americans are not well served by their current medical care arrangements. Compared to our major trading partners and competitors, we are less likely to be insured for the cost of care, and the care that we receive is almost certain to be more costly. Although U.S. medicine has produced many “miracles,” we are not the undisputed leader in medical innovation, only in the costliness and ubiquity of high-technology medicine. Most Americans “covered” by some form of health insurance still worry about its continuation should we or a close family member become seriously ill. Some of us are locked into employment we would gladly leave but for the potential catastrophic loss of existing insurance coverage.

While most commentators decry our peculiar ability to combine insecurity with high cost, the substantial reform of American medicine at the national level has been enormously difficult to achieve, and comprehensive reform has been impossible. This is not simply a description of the Clin...

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FOOTNOTES:

• [1] While substantial change took place in the United States in the decades from 1980 to 2000, most of it was privately generated. What is called the “managed care” movement altered the way most American physicians practice and get paid and had a lot to do with the changing ownership and shape of American hospitals. These changes stand in contrast to the publicly organized reforms in the United Kingdom (internal markets in the 1990s) or Canada (national health insurance in the period 1957–1971). For more on health reforms, especially “nonpublic change,” see Carolyn H. Tuohy, Accidental Logics: The Dynamics of Change in the Health Care Arena in the United States, Britain, and Canada (Oxford University Press, 1999).
• [2] For more on the public desire for substantial change in health care, see Robert J. Blendon and John M. Benson, “American’s Views on Health Policy: A Fifty-Year Historical Perspective,” March/April 2001, Health Affairs 20 (2): 33-46. A New York Times/CBS news survey in February 2007 confirmed this historical pattern, with “an overwhelming majority” saying “the healthcare system needs fundamental change or total reorganization.” Robin Toner, “U.S. Guarantee of Care for All, Poll Finds,” NY Times, March 2, 2007.
• [3] See, for elaboration on this episode, Alan Derickson, Health Security for All: Dreams of Universal Health Care in America (Johns Hopkins University Press, 2005), pp.52-71.
• [4] The American development of social insurance—and the character of the legislative initiatives of the 1930s—is illuminatingly (and briefly) discussed by one of Social Security’s most illustrious administrators, Robert Ball, in “The Original Understanding of Social Security: Implications for Later Developments,” in Marmor and Jerry Mashaw, eds., Social Security: Beyond the Rhetoric of Crisis (Princeton University Press, 1988), pp. 17-39.