Understanding the Complexity of the U. S. Health Care System: Can Free Market Ideology Respond to a Current Challenge?

I am a third-generation physician, a baby boomer, a parent, an American citizen, and a taxpayer. Since my recitation of the Hippocratic Oath 28 years ago during medical school orientation, I have found employment in the academic, federal, and private health care arenas. I am fiscally conservative, socially liberal, and a great believer in the U.S. Constitution. I am dependent upon the U.S. health care system for my livelihood, for my personal health care and the health care of my loved ones and their progeny, and philosophically for the health care of all people. Neither I nor my family has ever been without health care insurance. A discussion of politics and government policy demands a declaration of perspective.

The third edition of Governing Health: The Politics of Health Policyprovides a comprehensive framework from which to discuss the difficult issues facing the U.S. health care system today. The authors describe the many entities influencing health policy, including, but not limited to, Congress, the president, the U.S. Supreme Court, bureaucracy, special interest groups, and state governments, and they provide a historical perspective to the complex nature of changing health care policy using illustrations such as President Clinton's failed attempt to achieve radical health care reform in the 1990s and President Bush's success in adding Medicare drug prescription coverage in 2003. The intended audiences are health policy analysts, health system managers, political scientists, and health care professionals (such as me) seeking a better understanding of how policy is made and how the problems facing the health care system might be answered through new legislation.

The authors point out that substantial change in health care policy, for example the 1965 enactment of Medicare and Medicaid, requires a presidential agenda and a Congress with an overwhelming party majority in the president's favor. When these political planets are not aligned and the president's agenda is up against a more evenly divided Congress, substantial change to health care policy can be realized only with strict party unity, concessions to special interests, and compromise deals to sway votes, as was the case before President Bush signed into law the Medicare Prescription Drug, Improvement and Modernization Act of 2003. In the past 50 years, Presidents Roosevelt, Truman, Nixon, Carter, and Clinton tried to federally mandate universal health care for all American citizens, but they all failed due to the strength of countervailing special interests.

Surely, modern-day politics cannot fully explain the failure of the federal government to respond to rising health care costs, the rising number of Americans without health insurance, the projected bankruptcy of Medicare, diminishing entitlements to the poor, disparities in access and quality of health care delivery, the rate of medical errors, and tort reform. Rather, one must look to the underpinnings of the U.S. health care system as they are found in the U.S. Constitution, state sovereignty, and the ethics of the American citizen. The authors make reference throughout the text on the importance of these factors but leave the reader with the responsibility to search out their influence.

The U.S. Constitution, as intended by the Founding Fathers, framed our federal government but with a few exceptions—the right to a jury trial, the writ of habeas corpus, protection for contracts, and protection against ex post facto laws—did not explicitly guarantee or promote fundamental rights of the individual citizen. The Bill of Rights and the Reconstruction amendments following the Civil War explicitly expanded the list of fundamental rights, and over the years have been interpreted by the U.S. Supreme Court to implicitly guarantee certain fundamental rights, including the right to privacy, the right to use contraception, the right to marry, the right to procreate, the right to family relationships, the right to educate one's children, and the right to maintain bodily integrity. At...