Whatever happened to the reform of American health policy?BMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6966.1383 (Published 26 November 1994) Cite this as: BMJ 1994;309:1383
- Marilynn M Rosenthal
America's special quality—rampant diversity—got in the way
Keep two words in mind when trying to understand the reform of health policy in the United States: rampant diversity. The United States is a nation divided by business, ethnic, religious, social, and geographic interests. It has a difficult time agreeing on anything. Combine this with the historic weakening of the power of the presidency, the political parties' growing fractiousness, and increasingly sophisticated lobbying on behalf of special interests and the result, in 1994, is stalemate over the reform of health policy.
The central issues of reform debated in Congress and by the nation were universal coverage for all Americans, how to finance it, which benefits to include, how to control the cost, the federal government's role, and the degree of consumer choice. There were four differing major positions in the Democratic party and almost as many in the Republican party. The Democrats ranged from advocates of the single payer Canadian model, Clinton supporters, and the Cooper moderates to the old Southern traditionalists. And the Republican positions ranged from denial of any crisis (Senator Phil Gramm, Texas) to insurance reform (Senator Robert Dole, Kansas) to moderate reformists (Senator John Chaffee, Rhode Island). While most agree that all Americans should be covered, cross cutting and multiple positions emerged on the five other …