Health-Care Politics in the United States

by

Lauren Peterson, Colleen Grogan

• LAST MODIFIED: 28 October 2020
• DOI: 10.1093/obo/9780199756223-0320

Introduction

Comparative studies of health care in the United States and peer nations often highlight a number of distinct features of the American system including high costs, fragmentation, and health inequities. While unique political factors and institutions in the United States are prominent reasons for these disparities, there are also distinct interactions between American politics and cultural, economic, racial, and social factors. Many comprehensive overviews of American health politics and policy begin in the 20th century highlighting the important influence of global and national historical events, such as World Wars I and II, and social movements, including the civil rights movement. Yet, health-care politics in the United States also continues to be shaped by early American history, government institutions, and systems. To understand health-care policy in the United States, it is also necessary to consider the legacy of other non-health factors and their intersections with health politics, including slavery and ongoing racism, early Protestant notions of mortality and self-reliance, the localized nature of private charity and volunteerism, federalism, a public distrust of federal government, and the evolution of health professions, among other factors. Often these historical events and other cultural, economic, or social factors significantly shape public opinion, political participation, and health-care inequities, and in some cases, provide a window of opportunity to advance important health-care reforms. The structure of American government institutions, political parties and growing polarization, unique attributes of elected leaders or policy entrepreneurs, and the power of interest groups, particularly private actors in the health care delivery system, are all significant factors that shape health-care politics in the United States. Contemporary American public health policy literature focuses on efforts to reduce health inequities and improve access to health care as well as the politics of recent reform ideas that promote government regulation and investments in non-health factors such as the environment and social services to reduce population health inequities.

Historical Overviews

These works are a sample of the extensive body of literature that considers the role of politics in the evolution of the American health-care financing and delivery systems and the political challenge of advancing universal health coverage in the United States. Morone 2004 traces how American morality politics from the earliest roots of the United States to the present have shaped the modern health system, while Sledge 2017 details how those political and social factors affect public health infrastructure. Altman 2011 and Blumenthal and Morone 2010 compose absorbing narratives detailing the role of political actors in the transformation of American health policy from the 1930s through the enactment of the Affordable Care Act in 2010. Gordon 2009 similarly offers a comprehensive overview of American health politics and policy but also provides detailed analysis of the political factors that catalyzed the emergence and growth of private insurance. Jacobs and Skocpol 2015 and Starr 2013 present engaging overviews of contemporary American health politics with historical and political analyses primarily focused on the Affordable Care Act. Quadagno 2006 and Gottschalk 2000 lay out compelling theories to explain the role of private interests in limiting universal health coverage and expanding the private welfare state. Comparative overviews of American health politics, such as Fox 2014 and Tuohy 2018, are located under Theories of Health Politics and Policy Change. Historical overviews of the medical profession, such as Starr 2008 and Stevens 1998, are included under Politics of Health-Care Delivery Reform: American Hospital Association, American Medical Association, Physicians, and the Rise of Specialty Care; and a historical overview of health-care infrastructure, Stevens 1999, is included under Health-Care Delivery Infrastructure and the Politics of Cost-Cutting and Rationing. Historical analysis of health inequities, such as Nelson 2011 and Smith 2016, can be found under Disparities in Design of Health-Care Policies, while analysis of contemporary public health issues can be found under New Politics of American Public Health Policy.

• Altman, Stuart. Power, Politics, and Universal Healthcare: The Inside Story of a Century-Long Battle. Amherst, NY: Prometheus Books, 2011.

  Recounts the enactment of American health-care policies over the 20th century. Distills how key historical and cultural factors as well as political behavior have generated incremental health reforms and hindered the advancement of universal health coverage in the United States. Also provides a detailed account of the politics surrounding the passage of the Affordable Care Act in 2010, an accessible overview of the law, and lessons for contemporary health reform.

• Blumenthal, David, and James Morone. The Heart of Power: Health and Politics in the Oval Office. Berkeley: University of California Press, 2010.

  Engrossing historical narrative that examines the ways the personal experiences, perspectives, and political skills of individual American presidents have shaped health policy in the United States. Traces the evolution of the American health-care system from Franklin Roosevelt to Barack Obama, and highlights the critical role of the president and the Executive Branch in successful and unsuccessful efforts to expand health insurance coverage and implement market-based financing and delivery reforms.

• Gordon, Colin. Dead on Arrival: The Politics of Healthcare in Twentieth-Century America. Princeton, NJ: Princeton University Press, 2009.

  Draws on archival research to chronicle the evolution of the health-care system in the United States. Argues that the political challenges of advancing universal health coverage in the 20th century center on the emergence of private, employer-sponsored insurance and opposition from other private interests, such as medical professionals, unions, and political groups. Also explores how issues related to gender and race shape public and private responses to American health-care needs.

• Gottschalk, Marie. The Shadow Welfare State: Labor, Business, and the Politics of Health-Care in the United States. Ithaca, NY: Cornell University Press, 2000.

  Important work for understanding the entrenchment of the private welfare state in the United States and the evolution of health insurance during the second half of the 20th century. Focuses on organized labor, a uniquely powerful and frequently overlooked political actor in American health policy. Demonstrates the significant role of employers and unions in the protection of the private welfare state and defeat of universal health coverage during this period.

• Jacobs, Lawrence, and Theda Skocpol. Healthcare Reform and American Politics: What Everyone Needs to Know. Oxford: Oxford University Press, 2015.

  Well-written overview of the 2010 Affordable Care Act and contemporary American health politics for readers with limited knowledge of the health-care or political systems in the United States. Examines the effects of the legislation on health financing and service delivery in the United States five years after the enactment of the Affordable Care Act. Also provides a comprehensive glossary of key terms in American health politics.

• Morone, James A. Hellfire Nation: The Politics of Sin in American History. New Haven, CT: Yale University Press, 2004.

  Influential work on the role of religion in American political development. Lays out the evolution of morality politics in the United States, particularly on issues related to race, gender, and socioeconomic status. Demonstrates how morality politics permeate contemporary American political behavior and public policy. Applies this theory to a number of examples of contemporary issues in American health politics, including public health insurance, social welfare programs, abortion, and drug policy.

• Quadagno, Jill. One Nation, Uninsured: Why the US Has No National Health Insurance. Oxford: Oxford University Press, 2006.

  A comprehensive historical and political analysis of the failure to advance universal health coverage in the United States prior to the enactment of the Affordable Care Act. Lays out how American health policy during the 20th century was shaped by nongovernment actors and private interests, particularly the medical and insurance industries, as well as racial politics and desegregation. Also presents a profile of the medically uninsured during this period.

• Sledge, Daniel. Health Divided: Public Health and Individual Medicine in the Making of the Modern American State. Lawrence: University Press of Kansas, 2017.

  Foundational overview of American public health system. Examines the political, racial, and social factors that shaped the predominately centralized, government-led public health system and the fragmented, public-private medical system. Shows the central role of the American South, the region historically associated with some of the most significant infectious disease outbreaks and racial discrimination, in the formation of both systems. Also explores history of the Centers for Disease Control and Prevention.

• Starr, Paul. Remedy and Reaction: The Peculiar American Struggle over Healthcare Reform. New Haven, CT: Yale University Press, 2013.

  Chronicles American health politics with a particular focus on the period from the failure of the Clinton Health Plan in the 1990s through the passage of the Affordable Care Act in 2010. Argues the fragmentation of the existing health system, private interests, and American morality politics create a policy trap. Chapter 8 provides a concise overview of key issues in American health politics, such as equity and federalism.