Jacob S. Hacker is a bad-ass.

Jacob S. Hacker has a not-for-the-layperson book about the public/private nature of the American welfare state. His main issues are illustrating the path-dependent nature of the evolution of these programs, and he highlights the importance of applying the same type of government/institutional analytical framework to non-governmental actors in the game. He shows how organized labor played a vital role in securing pension benefits for all Americans but acquiescent on the health front; he shows the ruthless AMA lobby fighting against national health care in the 1930’s – and perhaps most importantly, how private insurance flourished in the absence of a governmental program between 1935 and 1950. After this point, every subsequent debate about national health care has really been a debate about expanding “private” (heavily subsidized) health insurance.

Hacker more recently authored the public option that was left out of the Senate bill.

This quote is from that turning point - where the future of the American health system had been decided by means of subterranean politics and the tax code. Not all at once, of course, but this is the point at which we know where the path is leading...

There was, in short, every sign that private health insurance had won out for employed Americans, just as there was every sign that Social Security would remain the core provider of retirement income.

No votes on this outcome had been taken. No grand alternatives had been put to citizens for a test. Indeed, judging by the debates that did transpire after 1950, there were no real choices to be made. Private insurance received ever more costly subsidies. Yet defenders of the voluntary way denied that government was implicated at all. Some Americans were well served and others were left out, but discussion of winners and losers was lost in the celebration of private progress and the complexities of tax tables. Americans had found themselves caught up in a fierce battle over national health insurance, but the increasingly privileged place of private insurance in the American social welfare regime prompted little debate at all.

And I love this quote, which perfectly sums up the role of the American government in health care in the 20th century:

The federal government had first built up the technological prowess of the medical complex, then become a generous subsidizer of private health insurance, and then finally stepped in as a largely passive financier of private medical care itself.

Cheery thoughts for a cold Friday afternoon.