Introduction: Who Shall Lead?

Almost thirty years ago health economist Victor Fuchs (1974) posed the question, "Who shall live?" In a world necessarily of scarce resources, with the rise of health care as a decidedly costly enterprise and increasing political pressures for expanding access to medical services, it was a substantively significant and well-timed query. Does the enormous investment in medical care really yield a healthier population? Fuchs (ibid.: 6) argued that "the connection between health and medical care is not nearly as direct or immediate as most discussions would have us believe" and noted the significant and then largely undervalued role of "genetic, environmental, and behavioral factors" in determining health status. As David Mechanic describes in his contribution to this special issue, these concerns of population health—including the social determinants of health—have reemerged as the subject of serious inquiry.

Implicit in "who shall live?" however, is "who shall decide?" and, one step further along, "who shall lead?" With insurance coverage declining, the health care sector absorbing an increasing share of the economy, and the need to make policy decisions—both public and private—about the organization, financing, and delivery of health care, as well as about how to influence the contours of the environmental, social, and behavioral attributes that affect health, it is equally important to explore who will take charge and under what conditions.

Fuchs at the time did not examine leadership issues writ large, no doubt for a number of reasons, but at least in part because the contemporary answer was readily apparent. Even as late as the early 1970s, the understood primary agent was the physician, whom Fuchs (ibid.) described as "the captain of the team," the one "who makes the key decisions. . . that account for the bulk of medical care costs." For much of the twentieth century, of course, physicians—and their collective representation in organized medicine—were captains of a domain that extended far beyond judgments about medical treatment. In Paul Starr's (1982: 5) classic account, building on Eliot Freidson's (1970) earlier work and what Robert Alford (1975) previously characterized as physicians' "professional monopoly," the authority that organized medicine had established tied to scientific legitimacy "spills over its clinical boundaries into areas of moral and political action." James Morone (1990: 254) sums up nicely the simple health care leadership paradigm of much of modern U.S. history: "A single pattern dominated American health care politics for most of the twentieth century: public power was ceded to the medical profession. Health care providers acted as trustees of health care policy. Legislation that they opposed was defeated; programs that were legislated were placed in their hands." ¹ The American Medical Association (AMA), which carried physician interests forward on the national stage, was unique among interest groups in laying claim to every institutional and financial resource that grants such organizations their political sway (Peterson 2001: 1152). The fragmented institutional arrangements of American government and other attributes of national and state politics afforded the opportunity to translate the well-organized professional monopoly into a policy monopoly (Peterson 1993 and forthcoming; see Marmor 2000: 77). Who shall lead? The docs. At that time.

Leadership of the health care domain, however, was beginning to be in flux by the time Fuchs crafted his book. The centrality of physicians was already coming into question. No longer was legislation that they opposed, in fact, necessarily defeated—at least in terms of a simple, declarative statement. The federal government and the states had long been involved in shaping features of the health care system—from biomedical research and hospital expansions to medical education and licensing—but always in terms largely dictated by organized medicine. In 1965, though, the AMA suffered its first major public policy defeat when Congress, over the AMA's strong objections, enacted a Medicare program for providing public health insurance coverage to the elderly that was even more expansive than the version proposed...