Lawrence D. Brown
The More Things Stay the Same
the More They Change
The Odd Interplay between Government
and Ideology in the Recent Political History
of the U.S. Health-Care System
Disentangling continuity from change in U.S. health-care policy is no task for those who crave instant intellectual gratification. The system is, of course, (in)famously stable: ever inclined to equate specialization and technology with quality, loath to impose planning on the independent institutional fragments of the "supply side state" (Jacobs 1995), unwilling to discard an employerbased approach to medical coverage, unable to acknowledge medical coverage as a right and to make such coverage universal and affordable, and quick to reject every real reform as a formula for "too much government."
The history of this same system, however, also shows much morphing and mutation: a "social transformation" (Starr 1982) brought industrial organization to cottage enterprises; competitive forces wrestled a provider-dominated sector into something more closely resembling a "normal" market; public regulatory innovations proliferated (professional standards review organizations, peer review organizations, health systems agencies, certificate-of-need programs, state rate setting, the prospective payment system and resource-based, relative-value-scale fee schedules in Medicare, the Health Insurance Portability and Accountability Act, and restrictions on managed care); broader coverage for low-income populations advanced (Medicaid expansions); new coverage for lower-income children emerged (the State Children's Health Insurance Program); Medicare finally added limited coverage for prescription