History and Health Policy in the United States: Putting the Past Back in

Rosemary A. Stevens

History matters. Shared perceptions of history can move audiences, offer powerful explanatory narratives for the present, suggest intriguing analogies with past events, and help build consensus around policy and management goals. When visible at all, however, policy history is often tailored to specific aims, interests, and agendas. Policy-making is strewn with dubious historical analogies and powerful myths.¹

One reason for studying the history of health policy is to avoid the pitfalls of thinking too narrowly about the present; in other words, to let one's imagination rove beyond the seductions of convenient but outdated partisan history. Among the pitfalls: assuming that past trends and/or current beliefs, as presented by advocates, will continue; uncritically accepting common or group belief in a new strategy in reaction to a perceived past; and neglecting the possibility that there may be promising alternative futures.

A second reason is that history is particularly important when policy directions seem unclear, as they are for health policy in most countries today, though perhaps most evidently in the United States. Without history, how are we to think about health policy in the twenty-first century? There are no ruling paradigms or canned solutions for health services in the United States (or for that matter in most other countries), save for rhetorical commitments to market and consumer principles and to providing care to every member of the population (while an estimated sixty percent of all health-care expenditures are incurred through the public sector and forty-five million Americans are uninsured). The lack of preconceived solutions may be good, allowing diverse, creative approaches to the organization, distribution, resource development,

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