Hacker J S, Skocpol T
Yale University, USA.
J Health Polit Policy Law. 1997 Apr;22(2):315-38. doi: 10.1215/03616878-22-2-315.
Following the demise of comprehensive health care reform in 1994, some reformers are seeking comfort in the successful "incremental" strategy for enacting Medicare that emerged out of President Harry Truman's failed campaign for national health insurance in 1948-50. But despite similarities between the Truman and Clinton health security efforts, overall contexts of government and politics are much less hospitable to governmentally funded reforms today than they were after Truman's defeat. Back then, market transformations and political dynamics were both pushing toward expanded access to health services and insurance coverage. Today, by contrast, both push in the opposite direction. The private insurance market is fragmenting, federal budgetary constraints stymie new programs, and the deficit dominates debate over existing programs. Equally important, a stable pro-reform coalition like that of Truman's day has yet to emerge, while a new and fiercely conservative corps of Republicans is championing coherent programmatic alternatives based on antigovernment premises. Although passage of the Kassebaum-Kennedy health insurance reform bill in 1996 unleashed a wave of enthusiasm about incremental health care reform, formidable political, fiscal, and technical obstacles continue to stand in the way of even relatively modest incremental solutions.
1994年全面医疗改革失败后，一些改革者从1948年至1950年哈里·杜鲁门总统争取国民健康保险失败后出现的、成功的医疗保险“渐进式”策略中寻求慰藉。但是，尽管杜鲁门和克林顿的医疗保障努力存在相似之处，但如今政府和政治的总体环境对政府资助的改革远不如杜鲁门失败后那般友好。那时，市场变革和政治动态都在推动扩大医疗服务和保险覆盖范围。相比之下，如今二者都朝着相反方向发展。私人保险市场正在分化，联邦预算限制阻碍新计划的实施，赤字主导着对现有计划的辩论。同样重要的是，像杜鲁门时代那样稳定的支持改革联盟尚未出现，而一群新的、极端保守的共和党人正在倡导基于反政府前提的连贯的计划替代方案。尽管1996年《卡斯鲍姆-肯尼迪医疗保险改革法案》的通过引发了对渐进式医疗改革的一阵热情，但即使是相对温和的渐进式解决方案，巨大的政治、财政和技术障碍仍继续阻碍着它们的实施。
