Since the passage of Medicare, the self-regulation characteristic of professionalism in health care has come under steady assault. While Canadian physicians chose to relinquish financial autonomy, they have enjoyed far greater professional autonomy over their medical judgments than their U.S. counterparts who increasingly have their practices micromanaged. The Affordable Care Act illustrates the ways that managerial strategies and a market model of health care have shaped the financing and delivery of health care in the U.S., often with little or no (...) evidence of their effectiveness. (shrink)

This essay describes how longstanding conceptions of professionalism in American medical care came under attack in the decades since the enactment of Medicare in 1965 and how the reform strategy and core provisions of the 2010 Affordable Care Act illustrate the weakening of those ideas and the institutional practices embodying them.The opening identifies the dominant role of physicians in American medical care in the two decades after World War II. By the time Medicare was enacted in 1965, associations of American (...) physicians were almost completely in charge of medical education, specialist certification, and the enforcement of professional norms on their members. Who could be a doctor, what education and training would be required, and what collegial oversight was operative was first a professional matter and only secondly implicated the state through malpractice or major corporations via the employment of physicians. (shrink)

At its inception, the Medicare program was seen as a way to bring the elderly into the mainstream of American medicine. The program after twenty years is increasingly viewed as an instrumentality to influence the nature and costs of American medicine. The first part of this article reviews the origins, history, and evolution of the Medicare program in order to explain how and why this change has come about. In the concluding section, the article explores further the implications of the (...) program's concentration on the aged, its uncertain notion of entitlement, and the bewildering character of the current claims of generational inequity allegedly imposed by Medicare's present outlays of $70 billion and its persistingly high rate of cost increases. Keywords: elderly, Medicare, health care CiteULike Connotea Del.icio.us What's this? (shrink)

We are now seeing a new wave of literature about the “crisis” of the welfare state. In the earlier wave, some critics charged that social spending significantly detracted from macro‐ or microeconomic performance, while others challenged the legitimacy or efficacy of welfare programs; a third group worried about the effect of macroeconomic problems on the viability of the welfare state. None of these criticisms can be said to have been satisfactory, and continued reiterations of them betray a lack of cross‐national (...) perspective and a priori reasoning about empirical matters. Works with greater historical depth and more recent studies constitute a much‐needed reaction against the “crisis” literature. (shrink)