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

By Rosemary A. Stevens; Charles E. Rosenberg et al. | Go to book overview

Charles E. Rosenberg


Chapter 1
Anticipated Consequences
Historians, History, and Health Policy

Policy is a familiar term. But like many indispensable words, it is not easily defined. In one sense it is descriptive: policy refers to current practice in the public sector. It also has a variety of other meanings: policy may imply an "ought" of planning and strategic coherence—or a real world "is" of conflict, negotiation, and compromise.1

As the history of United States health policy makes clear, moreover, the real world is not a very orderly place. Policies on the ground seem less a coherent package of ideas and logically related practices than a layered conglomerate of stalemated battles, ad hoc alliances, and ideological gradients, more a cumulative sediment of negotiated cease-fires among powerful stakeholders than a self-conscious commitment to data-sanctioned goals. But policy outcomes are hardly random; they embody the divergent rationalities and strategies of contending interests. Public-sector outcomes are determined by structured contention and contingency—not the prospective models and metrics of social scientists.2

Thus, the familiar dismissal of the historical community's potential contribution to policy seems, at least to this historian, paradoxical. Structured contention and contingency are history and so is contemporary policy—even if historians and historical data seem tangential to the demanding (and demanded) task of anticipating the consequences of particular present actions.3 From the historian's perspective, it is equally clear that recent policy—including ideological invocations of the past—constitutes a comparatively neglected area for research. Health policy tells us a great deal about the relationships among interest and ideology, formal structures and human need,

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