and Health Policy
JAMES A. MORONE
American health care policy is different from health policy in other industrial nations. The United States has no national health insurance, of course. However, that difference simply reflects a deeper contrast in the ways we Americans think about politics and health care. European health policy analysts regularly invoke a “solidarity culture”—a staunch belief in sharing resources and concern for what might be called “the people's health” (Morone 2000). European political cultures and institutions often reflect this collective ideal.
What most observers first notice about the American process is the unabashed pursuit of self-interest. In our dynamic (some would say raucous) system, stakeholders and interest groups jockey for advantage on every issue. One wily nineteenth-century politician put it famously after double-crossing a rival: “Politics is not a branch of the Sunday school business” (Morone 1998). This process poses a challenge for health specialists: groups pushing their own interests will stand up and oppose even the most unambiguous scientific findings.
Both scholars and laypeople usually view health policy largely through the lens of interest group politics. Stakeholders and politicians pursue their preferences. They negotiate with one another, cajole neutral parties, and mobilize their own supporters. Constitutional rules bound this process, and an elaborate network of rights protects each individual. The entire political system lurches along, operating its celebrated checks, balancing public programs with private markets, blunting radical changes, and producing incremental adjustments to the status quo. From this perspective, health science constantly wrestles with self-interested politics. Even robust findings are only as good as the policy coalition that assembles around them.
However, interest group politics is only the most obvious story. Two other traditions run through policymaking in the United States. First, Americans also share an intermittent legacy of cooperation—one that grows especially vivid during a crisis. National service programs (such as VISTA and AmeriCorps), town hall meetings (often employed by political campaigns), and attempts to stimulate citizen participation are all familiar efforts to tap the American communal legacy.