The corporate transformation of American health care: A study in institution building.

摘要

Any discussion of recent developments in American health care has to begin by recognizing a puzzling fact: Over many decades, all significant efforts to legislate comprehensive health reform have failed and yet the system has still undergone a profound, nation-wide restructuring. The changes have included declining physician autonomy and control over daily decision-making, the widespread innovation of new organizational strategies and structures, and a new sensibility about medicine as a basic economic good that is best allocated through markets. Understanding these important changes in health care organizations means thinking in new ways about the potential for widespread industry transformations, about the state's role in profound organizational change, and about the capacities of human actors within industries to forge and shape the institutional environments within which they operate.; This institutional history examines organizational change in American health care between 1965 and 1990 by drawing on insights from contemporary theories in organizational and economic sociology. It brings to bear a wide range of primary and secondary historical materials to follow alternative movements for health reform in the 1970s that emerged in response to an institutional crisis in the system movements to nationalize health insurance, to reorganize health care as a public utility, and to promote competitive markets in health care. The study analyzes and compares the failed and successful efforts at reorganizing health care much in the way that sociologists analyze social movements---as mobilizations oriented around a common vision of the way the world should be, where collective resources, strategy and social skill can make a difference in outcomes.; This study argues that the turn towards the market in American health care was not driven by the proven benefits of competition and business solutions in controlling inflation or reducing overall costs. The current system has come about through the combination of a unique set of social circumstances and strategic action by groups seeking change. The appeal of the market solutions in American, health care has been their consistency with fundamental currents in the political culture, and their ability to serve the varying interests of key stakeholders in the system, including physicians, hospital administrators, insurers and big business.