Role of ideology, opportunism and pragmatism in health care reform

Public opinion polls indicate that political ideology and party affiliation influence perceptions of health care reform. A 2009 poll found liberals and Democrats in Massachusetts claimed the state's health care reform was a success while conservatives and Republicans considered it a failure. In 2009 Democratic liberals supported a government option in the health reform bill but Obama withdrew it when faced with a strong backlash from conservative Republicans. This reflects Donabedian's typology of libertarian and egalitarian values that underlie health care policy. Libertarians defend individual freedom from government intervention and see access to health care as a societal reward for taking advantage of economic opportunities. Egalitarians support a government role to ensure universal access to health care and end health disparities. The ongoing US debate and legislation on health care reform features value orientations that reject compromise, encourage legislators to make deals that benefit their constituents and supporters rather than the nation as a whole, and discount pragmatic approaches that move systematically towards universal access over a number of years. The Patient Protection and Affordable Care Act is progressive, incrementally adding benefits and costs over a ten year period in order to remain deficit neutral. However, it has yet to gain support from a highly divided public. While a slim majority opposes the Act, over ten percent believe it is not liberal enough. On the conservative side several states passed health freedom acts that might exempt their citizens from the individual mandate to purchase insurance and legal challenges of the Constitutionality of the mandate are working their way through the court system. Based on the theories of Max Weber, this paper proposes that health care policies are of necessity value driven and are not readily amenable to instrumental cost benefit solutions. Politicians and media commentators gain power by advocating a particular value irrespective of the costs, foreseeable consequences or likelihood of success. The paper then presents the history of universal health care legislation in Australia as a possible future scenario for health politics in the US. Australia has a federal system with multiple interest groups. In 1984 Australia established a national universal insurance. Over the next forty years the two major Australian political parties have alternatively gained power and revised the balance between public and private funding of health insurance, leaving a trail of programs: Medibank, Medbank Mark II, Medicare, Australian Health Care and National Health Care.