The design of a health care reform program requires contributions from many disciplines. While we know that all disciplines are equal, we are also aware that some are more equal than others. I believe the record would show that, at this time and in this nation, economics is one of the fields of study that is “more equal” than others. Why are economists so important? What impact does the presence of these economists have on the development of health reform legislation? What price—if any—do all of us pay for the under-representation of various other disciplines? Some of the answers to these and other questions can be found in the accompanying essays by persons whose knowledge and experience lies in the field of political science. I propose to try to address these matters from the vantage of the discipline in which I was educated—political economy, as it was known at Johns Hopkins when I studied there.

It is not difficult to list some of the various factors that have propelled economists to the center of America's health care debate. Certainly it is the case that many of the issues raised by the health crisis and by proposals for health reform impinge on the economist's domain. Even without taking account of the imperialistic tendency of economists to view all of human behavior as that of rational economic actors and thus to lay claim to the study of virtually all human interactions, numerous matters do legitimately fall within the scope of economics and are of long-standing concern to economists.

There is a remarkable consensus that American medical care—particularly its financing and insurance coverage—needs a major overhaul. The critical unanimity on this point—what Paul Starr has rightly termed a “negative consensus”—bridges almost all the usual cleavages in American politics—between old and young, Democrats and Republicans, management and labor, the well paid and the low paid. We spend more on and feel worse about medical care than our economic competitors, with nine out of ten Americans (including Fortune 500 executives) telling pollsters that our health system requires substantial change. That is the good news for medical reformers in the Clinton administration, the Congress, and the polity at large.

The bad news for these reformers is that, for a variety of ideological and institutional reasons, American politics makes it very difficult to coalesce around a solution that reasonably satisfies the requirements for a stable and workable system of financing and delivering modern medical care. We have no assurance that the rare agreement on the seriousness of the nation's medical ills will generate the legislative support required for a substantively adequate and administratively workable program of reform.

Health care, like many other arenas of social policy, offers plentiful evidence both to those who picture the policy process as highly dynamic and innovative and to those who prefer to portray it as beset by deadlock and stalemate. Over the last two decades federal policymakers have invented an array of programs designed to make the system more efficient—health maintenance organizations, peer review organizations, health systems agencies, certificate-of-need, a prospective payment system, resource-based relative-value-scale fee schedules, to name the most prominent—but they have been unwilling to extend health coverage to the 17% or so of the nonaged population that lacks it or to change the nation's mixed public-private health insurance system in basic ways.

This pattern is less paradoxical than it may seem at first glance. A diffuse concern about the rising costs of care could well support a string of (largely ineffective) programs that apply gentle brakes without disturbing the system deeply, but benefit-expanding measures and still more federally sponsored programs to achieve a better balance between benefits and costs have met solid political obstacles. The public, fairly content with the system but poorly informed about its workings, wants immediate access to good care at “affordable” rates and rarely cares to hear about tradeoffs among these goals.

Before us is the question of whether or not the 103rd Congress will manage to do what no other U.S. Congress has ever accomplished: the enactment of a comprehensive reform of the way in which health care services are financed in the United States. Does a social science perspective give us a reason to believe that 1994 will be a legislative year that is different from all others? Conventional wisdom might well suggest a simple answer: “no.” Given what we know about the complexity of the issue, the enormous stakes in the system possessed by some of the most powerful private interests, the fragmentation of our governing institutions, the paralysis produced by deficit politics, and the general presumed enthusiasm in our system for caution and incrementalism, a large-scale transformation of health care financing by a legislature best known for parochialism, timidity, and gridlock would seem implausible at best. Can the institution that stimulated scholarly and popular assessments from Congress: The Electoral Connection (Mayhew 1974) to Hill Rat: Blowing the Lid off Congress (Jackley 1992) really overcome the well-known and thoroughly studied barriers to major policy change, especially in the wake of a health care reform proposal from President Bill Clinton that could legitimately prompt the estate of Rube Goldberg to sue for plagiarism (S 1757, HR 3600)?

Rather than “no,” however, the answer really is that we simply do not know. President Clinton's proposed Health Security Act is typically introduced in the media as the most ambitious social policy initiative since the New Deal and social security.

Ample evidence confirms that public opinion influences the policy-making process. Research suggests that public preferences are not simply translated into government policy; rather, policymakers' response to public opinion is conditioned or mediated by political and institutional processes (Jacobs, 1993a, 1993b, 1992a, 1992b; Jacobs and Shapiro, 1994a, 1994b; for discussion of this research see PS, March 1994, 9–38).

The passage and designing of health reform will depend in important respects on public attitudes toward health care and health reform. The interpretation of public opinion by the media and other political observers, however, is not a neutral process dictated by scientific methods; it is the product of institutional and political struggles for position and power.

Conventional wisdom regarding the public's health reform attitudes holds that Americans are narrowly self-interested, unambiguously antitax, and unwavering opponents of government regulation. Are these three sets of assumed attitudes supported by the available empirical evidence?

Here we take an historical approach to studying public opinion—one that identifies the patterns and trends of Americans' responses to identically worded questions asked in national opinion surveys.

Budget politics has always been an obstacle to adopting national health insurance. The questions of budget politics—the risk or size of deficits and the size of government—have a conservative effect. In any country, very few people would endorse deficits for their own sake. In America, support for larger government on principle, displacing the market, has rarely had close to majority support and has surely been diminishing. Defining social policy expansion as a budget issue is a standard tactic for persons opposed to the policy.

The events of the 1980s have in many ways made budget politics more of an obstacle to sensible health care reform—which I define as reform that insures all Americans, yet keeps this country from opening an even wider lead on the international field in the race to spend on health care.

During the 1960s a portion of elites such as economists, the press, and politicians would at least defend deficits in principle under some circumstances. Misinterpretation of the events of the 1970s, exaggerated arguments by economists who think that hyperbole is required in the political arena, the possibility that the 1980s deficits favored Republican constituencies, the fact that a Republican president was in office for those deficits, and the unprecedented scale of the deficit in full-employment terms during peacetime, combined in the 1980s to commit Democratic politicians, economists, and opinion leaders to at least the rhetoric of deficit-reduction. President Clinton has continued the process.

Among the many issues in the national health care debate is the role of the states. Some have asked whether the states can tackle health care on their own and have answered with a resounding “no.” Deborah Stone (1992), for example, argues that health care is too big a challenge for the states to handle: they lack sufficient autonomy from the federal government in certain areas and sufficient power over private interests in others.

But apparently, states are undeterred by such thinking. In the early 1990s, three states—Minnesota, Washington, and Florida—passed comprehensive bills incorporating elements of managed competition. Massachusetts, Oregon, and Vermont had already enacted (but not implemented) major reforms based upon different philosophies. And Hawaii led the way in 1974 with its enactment of an employer mandate.

Today, reform activity is everywhere. In 1993, 1,850 health care reform proposals were introduced in state legislatures; this year virtually every governor is working on some health care initiative. Even Lowell Weicker, Jr., governor of Connecticut, home to the nation's largest insurance companies, has announced his intention to provide universal coverage by 1997. The states are definitely not waiting around to see what the feds will do.

Americans have been debating national health insurance throughout the twentieth century. The content of this elusive reform has evolved far more than the tone of the debate. When Theodore Roosevelt championed health care reform (during the 1912 presidential campaign) he wanted to build a hardy stock of Anglo Saxons—health insurance would help deliver white America from race suicide (Dyer 1980; Ross 1913, 299–304). More than thirty years later, President Truman made health insurance the major domestic issue of his presidential campaign; his goal was an extension of the New Deal social welfare state (Starr 1982). Today, the reform that was once condemned as too costly is widely prescribed as cost control.

While the reform itself has changed, the debate that surrounds it remains entirely predictable. Theda Skocpol describes the contestants: On one side, self-confident, neo-Progressive experts touting rationalizing schemes. On the other, conservative critics deploying “ideological, emotionally charged arguments” (Skocpol 1994). The shrill rhetoric of opposition has alternately bemused and baffled observers. Compulsory insurance was “a dangerous device … announced by the German emperor” (in 1918), a force representing “social theory … socialism, even communism” (in 1932), “the keystone to the arch of socialism” and “a threat to every area of freedom as we have known it (by the 1960s).

In the September 1993 pages of this journal, I asked whether senators can illuminate the political and legal beliefs of Supreme Court nominees by questioning them at confirmation hearings (Comiskey 1993). Many observers of the confirmation process believe that a nominee's testimony can produce insights into the nominee's views that go beyond what is available from the nominee's public record. While such testimony has often proved barren in the past, these observers often express the view that better questioning of nominees can bring forth greater insights in the future (Carter 1988; Melone 1991; Rees 1983; Ross 1987). By contrast, I concluded that the political context in which Supreme Court nominations occur, the motives of participants in the confirmation process, and the incentives facing these participants will likely continue to inhibit illuminating testimony by nominees.

Since my previous paper was written before last summer's hearings on the nomination of Ruth Bader Ginsburg, this article examines those hearings. In some respects, her testimony resembled that of most recent nominees. In at least one respect—her candor on abortion—her testimony was a major departure from that of all recent nominees with the partial exception of Robert Bork.

The growing strength of the pro-life movement in the 1980s and the escalating violence of parts of the movement in the 1990s have led many commentators to question the value of the Supreme Court's decision in Roe v. Wade. Had the Supreme Court not lifted first trimester restrictions on abortion in its 1973 decision in Roe, so the argument runs, the states would have gradually enacted laws to change their restrictive abortion laws anyway, thus avoiding the agonizing national controversy that ensued.

One of the most prominent supporters of this position was Ruth Bader Ginsburg. During her confirmation hearings to the Supreme Court last summer, her views about the Roe decision re-entered the public arena. In the course of the hearings she asserted that like the guarantees of individual autonomy found in several Amendments, the right to an abortion should also be grounded in the equal protection provisions of the Constitution, thereby linking women's equality with the ability to control their reproductive function.

It is now possible while located in an office or home to search large journal collections, a Central Intelligence Agency world map database and world fact book, federal grant programs, law library catalogs, United States Supreme Court decisions, public opinion poll data, hundreds of general and specialized library catalogs, and many other information sources via computer. This article is intended for those who presently make little use of computers but who want to become familiar with the advantages and likely problems associated with performing such searches using one of the databases available online (by telephone line) on the Internet and five commercial online services. The article also discusses other uses for telephone-computer combinations such as electronic mail (e-mail).