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 Clinton Health Plan debacle of 1993–1994. On many occasions before and after the Second World War, comprehensive national reform was attempted (and in 1973–1974, appeared imminent). In all those instances, reform fell short of the necessary political majorities. Each of these failures has its own history, and in each there are many contributing causes. One fact remains: Americans have long been dissatisfied with the nation’s medical arrangements, but our political system has been unable to come up with a solution that satisfies enough of the public to overwhelm the institutional and interest group barriers to reform.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).
There is now once again a remarkable consensus that American medical care, particularly its financing and insurance coverage, needs a major overhaul. The critical unanimity on this point—what Paul Starr once rightly termed a “negative consensus”—bridges almost all the usual cleavages in American politics: between old and young, Democrats and Republicans, management and labor, the well paid and the low paid. The overwhelming majority of Americans (including Fortune 500 executives) tell pollsters that our medical system requires substantial change. That level of public discontent was, in 1993 and now agai...
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