Abstract

From the beginning of the twentieth century to its end, the structures of American health care delivery and financing reflected diverse and sometimes conflicting cultural priorities and commitments. Nowhere was this tension more evident than in the attempt to expand health care services to all Americans at an acceptable level of equity and affordability. At key moments throughout the century, organized efforts toward comprehensive restructuring of health care delivery and financing brought the debate to the public forum; and the language of this public debate provides an eloquent historical record of the tenacity of commitments to different formulations of freedom and fairness in American health care. ;My dissertation makes three contributions to the existing literature on the American health care debate. First, it traces the ways in which pluralistic commitments were represented both in the actual structures of health care delivery and financing, and in the language with which those arrangements were discussed and debated through the last century. Drawing heavily both from the public record and from internal organizational discussions, I use institutional theory in analyzing the efforts of major structural actors in American health care to accommodate themselves to, and simultaneously direct, competing understandings of freedom and fairness in broader community and social environments. ;By incorporating key elements of American cultural mythology within their institutional narratives, these actors legitimated themselves quite successfully over the decades, but their legitimacy was repeatedly challenged by unmet health care needs of millions of Americans, and by persistently escalating health care costs. Accordingly, the second contribution of my dissertation is an analysis of organized attempts to meet these challenges through restructuring and reform, with particular attention to the moral and cultural arguments that characterized those attempts. ;The failure of prevailing structures to adequately address these challenges has brought the unfinished business of health care security into a new millennium, and has made further debate inevitable. My research makes its third contribution in drawing from the lessons and language of history, and proposing a conceptual foundation upon which future arguments for greater levels of equity and universality in health care might build