Health Care Policy in Contemporary America

This collection, originally published as an issue of the Journal of Policy History, offers a historical perspective on how political ideas and technological developments have shaped contemporary health care policy. The essays trace the shift from the group to the individual as the focus of policy planning and the influence of late-twentieth-century challenges to scientific expertise in the formation of government programs. They show that while advances in science and technology may give direction to debates, health care policies spring from diverse sources including consumer activism and industry pressures.

Covering a wide range of subjects, from Blue Cross to the care of mental patients, these articles expand the discussion of health policy beyond the debate over national health insurance. The essays work well together. For example, three of the pieces discuss the process by which the federal Food and Drug Administration (FDA) approves new pharmaceuticals, food additives, and other substances. Amy Sue Bix’s insightful piece, “Disease Chasing Money and Power: Breast Cancer and AIDS Activism Challenging Authority,” demonstrates how organized advocates shifted the funding priorities of the federal government and challenged the FDA’s drug approval time line. Similarly, the 1977 ban on the artificial sweetener saccharin resulted not from scientific consensus but from the majority rule of interested constituents that included consumers, producers, and the diet industry, as Alan I. Marcus convincingly shows in “Sweets for the Sweet: Saccharin, Knowledge, and the Contemporary Regulatory Nexus.” In a similar fashion, James Harvey Young’s well-researched “Health Fraud: A Hardy Perennial” stresses that pressure from industry and congressional interests prevented the FDA from effectively eliminating quackery, especially in the area of nutritional supplements. Read together, these pieces demonstrate the benefits and perils of the challenging of scientific expertise in the regulatory process. While advocacy resulted in increased funding for breast cancer and AIDS research, serious diseases without similar vocal constituents, such as heart disease, have failed to keep pace in funding despite their greater impact on society. In addition, the federally funded Office of Alternative Medicine, a part of the National Institutes of Health, has been co-opted by the congressional interests that created the office, despite directors who have tried to maintain scientific standards for research and distributing research dollars.

While some of the essays concentrate on social changes, others examine the impact of changing technologies and the shifting perception of technology upon decision making. For example, Diane Paul’s insightful “From Eugenics to Medical Genetics” explores how new medical procedures (such as amniocentesis) and shifting discourses (from a eugenics program of protecting society to one of medical genetics designed to serve the interests of individual families) shaped physicians’ advice to couples seeking to have children. Gerald Grob’s thorough discussion of the deinstitutionalization of mental patients, which investigates both changing medical options and social programs, demonstrates that policies that appear to make up a deliberate, unified program may well be the unintended consequences of disparate government activities. In contrast, David Rosner and Gerald Markowitz’s careful discussion of the role of the American labor movement in the emergence of Blue Cross insurance and Hamilton Cravens’ exploration of the self-esteem movement focus more on social than technological issues.

Most of the articles contain good primary source research and useful bibliographic material on subjects that have heretofore been discussed primarily in a journalistic context. Several of the pieces assume a familiarity with government agencies and policies and with contemporary activist groups; others better define agencies and introduce an advocacy group’s membership and goals. Readers may wish for more evidence for assertions such as the one found in Craven’s article, “Postmodernist Psychobabble,” that since World War II “Americans have acted and spoken as if they lived in a world of individuation, fragmentation, of rebellion against larger entities or collectives of any sort whatsoever” (144).

This readable volume would work quite well in the classroom, especially if used in conjunction...