The Health of Nations: Public Opinion and the Making of American and British Health Policy (review)

The Health of Nations sets out to trace the significance of public opinion to twentieth-century British and American health policy. Focusing on the negotiations that led up to the 1946 British National Health Service Act and the 1965 American Medicare Act, Lawrence Jacobs explores the growing sensitivity of politicians and government officials to public beliefs about health-care provision. He argues that during the 1930s politicians and officials in both countries sought to manipulate public opinion through public relations campaigns, gathering information on popular beliefs and preferences—at first in informal ways, and later, more systematically through polling and other methods. He then discerns what he calls a “recoil” effect: politicians and officials in both countries began to take account of public opinion in formulating policy in ways that had not existed before. This new sensitivity to public opinion reached a height in both countries after landslide electorial victories—those of the British Labour Party in 1945, and of the American Democratic Party in 1964—and allowed policymakers to challenge powerful vested interests opposed to radical change.

The broad strands of this argument are set out in the first three chapters, which also include a discussion of the ways in which differences in health-care provision in Britain and America shaped public understandings and expectations. Thus, Jacobs claims that the Britons’ comparatively greater experience of governmental provision in health care facilitated the public acceptance of state provision of a comprehensive range of medical services, universally available, free of charge at the point of delivery, and financed through direct taxation. In contrast, he claims, Americans did not want or understand direct state involvement in hospital and general medical care, preferring to funnel government money into a privately run health system for selected groups such as the elderly. The rest of the book weaves historical detail into the basic argument, and a conclusion elaborates its policy implications.

Jacobs sees his account as a critique of Weberian policy analysis, which tends to view change or advance in bureaucratic organizations as the product of their technical superiority over other forms of organization. Thus Jacobs claims that Weberians expect what they describe as an institution’s objective administrative capacity to be the primary factor in determining change. Moreover, he suggests Weberians claim that the potential of state actors to define and pursue goals independent of the interests of leading societal groups is a function of this administrative capacity. Put simply, the only groups that count in this model are state officials and politicians on the one side, and interest groups and powerful individuals on the other. However, Jacobs argues that broader cultural values also shape bureaucratic organizations. The recognition that bureaucrats’ “technical” assessments are not objective but are socially constructed, he claims, means that we must take into account the ways in which public opinion informs the policy process and hence the shape of bureaucratic organizations.

It is here that the limits of the argument become clear. Jacob’s account is inclined to blur the distinction between popular beliefs about health-care provision and the political, official, and pollsters’ constructions of such beliefs. This occurs in three ways. First, he tends to reduce popular beliefs about health-care provision to public “understandings” of official policy; this top-down model necessarily limits his ability to show how broader cultural attitudes toward health-care provision might have shaped official thinking. Second, Jacobs tells us little about how knowledge of “the public” was constructed and negotiated among politicians, pollsters, and interest groups—though some of the debates that he describes suggest that different commentators had very different perceptions of what constituted public opinion. Finally, he often fails to locate policymakers culturally or socially, so that the meaning of their constructions of the public and of public opinion is unclear. For example, some of the British officials he quotes saw the public as divided along class...