Medicare and the American state: The politics of federal health insurance, 1965-1995

This dissertation is a study of Medicare politics from 1965-1995. The central question is what have been the major political influences on Medicare policymaking? I investigate the influence of elections, public opinion, interest groups, state actors, policy feedbacks, and ideas on federal health policy. I argue that federal policymakers have exerted a much stronger independent influence on Medicare policy than is expected by the existing literature, while the impact of public opinion and interest groups on Medicare has been weaker than anticipated by relevant theories. I contend that Congress has been a primary source of independent Medicare policy, contravening the prevailing image of the U.S. national legislature as vulnerable to interest group pressures and as incapable of, or disinterested in, substantive policymaking.;The dissertation addresses two additional questions: what have been the major patterns in Medicare politics since its enactment, and what does the Medicare case reveal, more broadly, about the politics of the American welfare state? I find that there have been three primary patterns in Medicare politics corresponding to different areas of program policy. Benefits policy has been characterized by non-distributive politics; the dominant patterns has been the absence of consistent expansion in program benefits. The core pattern in financing policy has been crisis politics; Medicare's financing arrangements have produced intermittent "bankruptcy crises" that have played a critical role in the adoption of program reforms. Regulatory policy has been shaped by budgetary politics; variation in the strength of Medicare regulation of medical providers is explained by changes in federal budgetary conditions.;Finally, I argue that a defining feature of Medicare's political development has been its divergence from the expectations created for federal health insurance by Social Security's experience from 1935-1965. Medicare has not imitated the expansionary pattern of Social Security benefits, nor has it developed into a broader system of national health insurance, as its architects envisioned. This study thus points to important distinctions in the programmatic histories of Medicare and Social Security and in the politics of American social insurance.