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Securing care: Freedom and fairness in the twentieth-century American health care debate.

机译：确保医疗保健：20世纪美国医疗保健辩论中的自由与公平。

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From the beginning of the twentieth century to its end, the structures of American health care delivery and financing reflected diverse and sometimes conflicting cultural priorities and commitments. Nowhere was this tension more evident than in the attempt to expand health care services to all Americans at an acceptable level of equity and affordability. At key moments throughout the century, organized efforts toward comprehensive restructuring of health care delivery and financing brought the debate to the public forum; and the language of this public debate provides an eloquent historical record of the tenacity of commitments to different formulations of freedom and fairness in American health care.; My dissertation makes three contributions to the existing literature on the American health care debate. First, it traces the ways in which pluralistic commitments were represented both in the actual structures of health care delivery and financing, and in the language with which those arrangements were discussed and debated through the last century. Drawing heavily both from the public record and from internal organizational discussions, I use institutional theory in analyzing the efforts of major structural actors in American health care to accommodate themselves to, and simultaneously direct, competing understandings of freedom and fairness in broader community and social environments.; By incorporating key elements of American cultural mythology within their institutional narratives, these actors legitimated themselves quite successfully over the decades, but their legitimacy was repeatedly challenged by unmet health care needs of millions of Americans, and by persistently escalating health care costs. Accordingly, the second contribution of my dissertation is an analysis of organized attempts to meet these challenges through restructuring and reform, with particular attention to the moral and cultural arguments that characterized those attempts.; The failure of prevailing structures to adequately address these challenges has brought the unfinished business of health care security into a new millennium, and has made further debate inevitable. My research makes its third contribution in drawing from the lessons and language of history, and proposing a conceptual foundation upon which future arguments for greater levels of equity and universality in health care might build.
机译：从二十世纪初到末期，美国医疗保健的提供和筹资结构反映了多种多样的，有时相互冲突的文化优先事项和承诺。在试图以可接受的公平性和可负担性向所有美国人扩展医疗保健服务方面，这种紧张局势最明显。在整个世纪的关键时刻，为全面调整医疗服务和筹资而进行的有组织的努力将辩论带入了公共论坛；公开辩论的语言提供了雄辩的历史记录，证明了对美国医疗保健中不同形式的自由和公平的承诺的坚韧不拔。我的论文对有关美国医疗保健辩论的现有文献做出了三点贡献。首先，它追溯了在卫生保健提供和筹资的实际结构中以及在上个世纪讨论和辩论这些安排所用的语言中多元承诺的表达方式。我从公共记录和内部组织讨论中大量汲取了经验，我使用制度理论分析了美国卫生保健中主要结构参与者的工作，以使其适应并同时指导更广泛的社区和社会环境中对自由和公平的相互竞争的理解。 。;通过将美国文化神话的关键元素纳入其机构叙述中，这些参与者在过去的几十年中非常成功地使自己合法化，但是他们的合法性反复受到数百万美国人未满足的医疗保健需求以及不断上升的医疗保健成本的挑战。因此，我论文的第二个贡献是对通过改组和改革来应对这些挑战的有组织的尝试进行了分析，并特别注意了代表这些尝试的道德和文化论点。现行结构未能充分应对这些挑战，使未完成的医疗保健业务进入了一个新的千年，不可避免地引起了进一步的辩论。我的研究在吸取历史教训和历史语言的基础上做出了第三次贡献，并提出了一个概念性基础，可以为将来在医疗保健中实现更高水平的公平性和普遍性奠定基础。

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