| What explains the absence of universal health insurance coverage in the United States? There is no one politics of health care or one explanation for the lack of universal coverage; there are, instead, different patterns of politics at different stages of policy development. Yet a unique and critical relationship has existed between Social Security and the development of health insurance. Intimidated by organized medicine in 1935, President Roosevelt excluded universal health insurance coverage from the Social Security Act so that the program could pass in Congress. For the next three decades the American Medical Association (AMA) continued to prevent any public, contributory health insurance scheme from passing, largely due to its superior lobbying. But by the mid 1960s, Social Security had evolved into the best---if not only---vehicle for overcoming the AMA's formidable interest-group opposition and, in the process, incrementally achieving the goal of universal coverage. Medicare's passage in 1965 represented the first major step.; Policy-makers' success with incremental expansion, however, also had detrimental consequences. Specifically, Social Security and Medicare's accumulated costs eventually emerged as a major impediment to the goal of universal coverage. From the mid 1970s on, universal coverage became financially "crowded out," in part by the programs that many envisioned would facilitate its achievement. Once the payroll tax became solely devoted to covering Social Security and Medicare's rapidly increasing costs, policy-makers grew convinced that they could not raise it for any additional commitments. They chose, instead, to pursue alternative financing proposals for increasing health insurance coverage. All of them proved politically futile because any substantial broadening of the government's role in health insurance after the mid-1970s either threatened entrenched, private interests (such as the insurance industry) or risked encouraging employers to discontinue providing coverage for their employees. Essentially, attempts at forging new policy paths became blocked by the constellation of interests surrounding old, institutionalized ones: the private path of tax-subsidized, employer-provided health insurance and the public path of different government programs for targeted segments of the population. With the myriad of elected leaders, interest-groups, and organizations supporting these two paths, political actors have found comprehensive change to be inordinately difficult if not virtually impossible. |
