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Institutions and Culture Health Policy and Public Opinion in the U.S. and Britain

Published online by Cambridge University Press:  13 June 2011

Lawrence R. Jacobs
Lawrence R. Jacobs
Affiliation:
University of Michigan
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Abstract

This article argues that explaining institutional differentiation requires the incorporation of public preferences and understandings into accounts of state development. Using primary evidence concerning policy discussions and public opinion, it suggests that culture determined the specific features of both the British National Health Service Act of 1946 and the American Medicare Act of 1965, as well as the differences between them. Examining the interaction of institutions and culture inserts democratic standards into the top-heavy Weberian discussions of state autonomy and accounts for the seemingly inexplicable failure of policymakers to ensure cost control over the new health programs.

Type
Research Article
Information
World Politics , Volume 44 , Issue 2 , January 1992 , pp. 179 - 209
Copyright
Copyright © Trustees of Princeton University 1992

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References

1 Schumpeter, Joseph, Capitalism, Socialism and Democracy (London: Allen and Unwin, 1976)Google Scholar.

2 Key, Public Opinion and American Democracy (New York: Alfred A. Knopf, 1961)Google Scholar; Evans, Peter and Stephens, John, “Studying Development since the Sixties,” Theory and Society 17, no. 5 (1988)CrossRefGoogle Scholar.

3 Although I refer to the British NHS Act of 1946, this act formally applied to England and Wales; Scotland was not incorporated into the “British” health service until the passage of the 1947 NHS Act.

4 Almond, Gabriel A. and Powell, G. Bingham, Comparative Politics: A Developmental Approach (Boston: Little Brown, 1966)Google Scholar.

5 Recognizing the crude nature of these comparative distinctions, scholars have recently modified the simple dichotomies of weak-strong states and mobilized-unmobilized working classes. For examples of the former, see Katzenstein, Peter, Corporatism and Change (Ithaca; N.Y.: Cornell University Press, 1984)Google Scholar; and idem, Small States in World Markets (Ithaca, N.Y.: Cornell University Press, 1985)Google Scholar. For examples of the latter, see Korpi, Walter, The Democratic Class Struggle (London: Routledge and Kegan Paul, 1983)Google Scholar; and Quadagno, Jill, The Transformation of Old Age Security: Class and Politics in the American Welfare States (Chicago: University of Chicago Press, 1988)Google Scholar.

6 Weber, Max, “Bureaucracy,” in Gerth, H. H. and Mills, C. Wright, eds., From Max Weber (New York: Oxford University Press, 1946), 214Google Scholar. Weberian research has developed in diverse directions. This article is concerned with one variant, which emphasizes the “technical” organizational attributes of states. The work of other Weberian scholars emphasizes the role of nontechnical factors, such as mass public attitudes. For examples, see Katzenstein (fn. 5, 1984 and 1985); and Stepan, Alfred, The State and Society: Peru in Comparative Perspective (Princeton: Princeton University Press, 1978)Google Scholar.

7 Weber (fn. 6), 214–16.

8 Skowronek, Stephen, Building a New American State: The Expansion of National Administrative Capacities (New York: Cambridge University Press, 1982), 290CrossRefGoogle Scholar; Orloff, Ann and Skocpol, Theda, “Why Not Equal Protection? Explaining the Politics of Public Social Spending in Britain, 1900–1911, and the United States, 1880s–1920,” American Sociological Review 49 (December 1984)CrossRefGoogle Scholar.

9 Skowronek (fn. 8); Orloff and Skocpol (fn. 8); Orloff, Ann, “The Political Origins of America's Belated Welfare State,” in Weir, Margaret, Orloff, Ann, and Skocpol, Theda, eds., The Politics of Social Policy in the United States (Princeton: Princeton University Press, 1988)Google Scholar.

10 Skocpol, Theda and Finegold, Kenneth, “State Capacity and Economic Intervention in the Early New Deal,” Political Science Quarterly 97 (Summer 1982)CrossRefGoogle Scholar.

11 Katzenstein, Peter, ed., Between Power and Plenty: The Foreign Economic Policies of Advanced Industrial States (Madison: University of Wisconsin Press, 1978)Google Scholar.

12 Orloff and Skocpol (fn. 8).

13 Skocpol and Finegold (fn. 10), 268.

14 Orloff and Skocpol (fn. 8).

15 Geertz, Clifford, The Interpretation of Culture (New York: Basic Books, 1973)Google Scholar; Giddens, Anthony, Central Problems in Social Theory (Berkeley: University of California Press, 1979)CrossRefGoogle Scholar; E. P. Thompson, “The Poverty of Theory or an Orrery of Errors,” and idem, “The Peculiarities of the English,” in Thompson, , The Poverty of Theory and Other Essays (New York: Monthly Review Press, 1978)Google Scholar; idem, The Making of the English Wording Class (London: Vintage Books, 1966)Google Scholar; Berger, Peter and Luckmann, Thomas, The Social Construction of Reality (Garden City, N.Y.: Doubleday, 1966)Google Scholar; Douglas, Mary, In the Active Voice (London: Routledge and Kegan Paul, 1982)Google Scholar; idem, Natural Symbols (Harmondsworth: Penguin, 1970)Google Scholar; Wildavsky, Aaron, “Choosing Preferences by Constructing Institutions: A Cultural Theory of Preference Formation,” American Political Science Review 81 (March 1987)CrossRefGoogle Scholar.

16 The knowledge of social actors is based on their explicit monitoring of their environment as well as their tacit understanding of their society. Whereas explicit monitoring means that individuals can give reasons and rationalize their conduct, tacit understanding refers to an individual's stock of unarticulated knowledge, which he/she uses implicitly to orient him/herself and to interpret the acts of others. See Giddens (fn. 15); Brown, Steven, Political Subjectivity (New Haven: Yale University Press, 1980)Google Scholar; Ortner, Sherry, “Theory in Anthropology since the Sixties,” Comparative Studies in Society and History 26 (January 1984)CrossRefGoogle Scholar.

17 Wildavsky (fn. 15).

18 Both neo-Marxists and non-Marxists agree that it is not possible to “decode” and trace human behavior back to its “real” material essence. For examples, see Thompson (fn. 15, 1978 and 1966); Katznelson, Ira, “Working-Class Formation: Constructing Cases and Comparisons,” in Katznelson, and Zolberg, Aristide, eds., Working Class Formation (Princeton: Princeton University Press, 1986)Google Scholar; Hunt, Lynn, Politics, Culture, and Class in the French Revolution (Berkeley and Los Angeles: University of California Press, 1984)Google Scholar; and Eckstein, Harry, “A Culturalist Theory of Political Change,” American Political Science Review 82 (September 1988)CrossRefGoogle Scholar. The neo-Marxist argument that human behavior is not simply the product of material forces has been roundly criticized, alternately for abandoning the orthodox Marxist concern with economics and for continuing to overemphasize material conditions. For an example of the former, see Johnson, Richard, “Edward Thompson, Eugene Genovese, and Socialist-Humanist History,” History Workshop Journal 6 (Autumn 1978)CrossRefGoogle Scholar. For examples of the latter, see Hunt, Lynn, ed., The New Cultural History (Berkeley and Los Angeles: University of California Press, 1989)CrossRefGoogle Scholar; and Jones, Gareth Stedman, Languages of Class: Studies in English Wording Class History (Cambridge: Cambridge University Press, 1983)Google Scholar.

19 Inglehart, Ronald, The Silent Revolution: Changing Values and Political Styles among West-em Publics (Princeton: Princeton University Press, 1977), 4Google Scholar; idem, Culture Shift in Advanced Industrial Society (Princeton: Princeton University Press, 1990)Google Scholar; Almond, Gabriel A. and Verba, Sidney, The Civic Culture: Political Attitudes and Democracy in Five Nations (Princeton: Princeton University Press, 1963)CrossRefGoogle Scholar.

20 Jacobs, Lawrence and Shapiro, Robert, “Public Opinion and the New Social History: Some Lessons for the Study of Public Opinion and Democratic Policy Making,” Social Science History 13 (Spring 1989)CrossRefGoogle Scholar; Jacobs, Lawrence, “A Social Interpretation of Institutional Change: Public Opinion and Policy Making in the Enactment of the British National Health Service Act of 1946 and the American Medicare Act of 1965” (Ph.D. diss., Columbia University, 1990), chap. 3Google Scholar.

21 Eckstein (fn. 18).

22 Smith, Francis B., The People's Health, 1830–1900 (New York: Holmes and Meier, 1979)Google Scholar; Meacham, Staudish, A Life Apart: The English Working Class, 1890–1914 (Cambridge: Harvard University Press, 1977)Google Scholar; Abel-Smith, Brian, Hospitals, 1800–1948 (London: Heinemann, 1964)Google Scholar; Hodgkinson, Ruth, The Origins of the National Health Service: The Medical Services of the New Poor Law, 1834–71 (Berkeley: University of California Press, 1967)Google Scholar.

23 Quadagno, Jill, Aging in Early Industrial Society: Work, Family, and Social Policy in Nineteenth-Century England (New York: Academic Press, 1982), 137–38Google Scholar.

24 Lubove, Roy, The Struggle for Social Security, 1900–1935 (Cambridge: Harvard University Press, 1968), 106–11Google Scholar.

25 de Tocqueville, Alexis, in Mayer, J. P., ed., Democracy in America (New York: Anchor Books, 1969)Google Scholar; Ostrogorski, Moisei Y., Democracy and the Organization of Political Parties, 2 vols. (London: MacMillan, 1902)Google Scholar; Hartz, Louis, The Liberal Tradition in America (New York: Harcourt Brace Jovanovich, 1955)Google Scholar.

26 Kemler, Edgar, The Deflation of American Ideals: An Ethical Guide for New Dealers (Seattle: University of Washington Press, 1947), 166Google Scholar.

27 Shonick, W., “Early Developments and Recent Trends in the Evolution of Local Public Hospitals,” Annual Review of Public Health 5 (1984), 54CrossRefGoogle Scholar; Fox, Daniel, Health Policies, Health Politics: The British and American Experience, 1911–1965 (Princeton: Princeton University Press, 1986), 74–77Google Scholar; Rosenberg, Charles, “And Heal the Sick,” Journal of Social History 10 (June 1977), 448Google Scholar; Starr, Paul, The Social Transformation of American Medicine (New York: Basic Books, 1982), 149–51, 178–80Google Scholar.

28 Payne, Stanley, “Some Opinion Research Principles Developed through Studies of Social Medicine,” Political Opinion Quarterly 10 (Spring 1946), 93–98Google Scholar; Schiltz, Michael, Public Attitudes toward Social Security, 1935–65 (Washington, D.C.: GPO, 1970)Google Scholar; Hirschfield, Daniel, The Lost Reform: The Campaign for Compulsory Health Insurance in the United States (Cambridge: Harvard University Press, 1970)CrossRefGoogle Scholar.

29 Page, Benjamin and Shapiro, Robert, “Effects of Public Opinion on Policy,” American Political Science Review 77 (March 1983)CrossRefGoogle Scholar; Shapiro, Robert, “The Dynamics of Public Opinion and Public Policy” (Ph.D. diss., University of Chicago, 1982)Google Scholar; Erikson, Robert, “The Relationship between Public Opinion and State Policy: A New Look at Some Forgotten Data,” American Journal of Political Science 22 (February 1976)Google Scholar; Monroe, Alan, “Consistency between Public Preferences and National Policy Decisions,” American Political Quarterly 7 (January 1979)Google Scholar; Weissberg, Robert, Public Opinion and Popular Government (Englewood Cliffs, N.J.: Prentice-Hall, 1976)Google Scholar.

30 Page and Shapiro (fn. 29) use temporal asymmetries to identify causal priority.

31 For examples, see Monroe (fn. 29); and Page and Shapiro (fn. 29).

32 In order to quantify governmental policy decisions, investigation of the relationship between public preferences and policy-making has counted either the votes of legislators or the overall vote or decision of a collective political institution (e.g., congressional passage of a bill). The problem, though, is that by aggregating multiple policy decisions, this research has ignored the decisions of policymakers during the “prevote” stage.

33 Almond and Powell (fn. 4); Heclo, Hugh, Modern Social Politics in Britain and Sweden (New Haven: Yale University Press, 1974)Google Scholar; Skowronek (fn. 8); Orloff and Skocpol (fn. 8).

34 Derthick, Martha, Policymaking for Social Security (Washington, D.C.: Brookings Institution, 1979)Google Scholar.

35 Louis Harris, “A Study of the Primary Outlook in South Carolina,” December 1961, RFK Papers, Attorney General's Correspondence, Box 15, Kennedy Library, Boston; Schiltz (fn. 28), 140, 170, 194–95; Erskine, Hazel, “The Polls: Health Insurance,” Public Opinion Quarterly 39 (Spring 1975), 134CrossRefGoogle Scholar.

36 By the early 1960s polls had been tracking public attitudes toward government financing of the medical expenses of the poor for nearly thirty years; the first poll conducted following the passage of the Kerr-Mills program (1960) for providing medical relief recorded the lowest percentage of approval and the highest rate of disapproval for government financing of health care for the poor. See Schiltz (fn. 28), 128, 158.

37 Cohen, Wilbur to President Kennedy, May 10, 1963Google Scholar, POF, Box 79A Kennedy Library, Boston; Ullman, Al (committee member), Statement, U.S. Congress, House Ways and Means Committee, Hearings on HR1, 89th Cong., 1st sess., 1965, 340–41Google Scholar; Cohen, Wilbur to President Johnson, “Congressmen Herlong and Curtis' ‘Eldercare Act of 1965,’ ” February 25, 1965Google Scholar, Ex LE/IS1, Box 75, Johnson Library, Austin.

38 Cohen, Wilbur, interview with author, Austin, April 1, 1987Google Scholar; Celebrezze, Anthony (secretary, HEW), Testimony, U.S. Congress, House Ways and Means Committee, Hearings on HR1, 89th Cong., 1st sess., 1965, 2–3Google Scholar; “Suggested Opening Statement by the President for Next Press Conference,” June 12, 1962, Sorenson, T. Papers, Box 36, Kennedy Library, Boston; Cohen (fn. 37, May 10, 1963)Google Scholar.

39 Cohen, Wilbur, Testimony, U.S. Congress, House Ways and Means Committee, Hearings on HR1, 89th Cong., 1st sess., 1965, 93Google Scholar.

40 Wilbur Cohen (fn. 38); Gordon, K. (director, BOB), Testimony, U.S. Congress, House Ways and Means Committee, Hearings on HR1, 89th Cong., 1st sess., 1965, 802–3Google Scholar; Celebrezze (fn. 38), 2–3; President Kennedy to president of the Senate, February 13, 1961, M. Feldman Papers, Box 27, Kennedy Library, Boston; Conley, Reginald G. (HEW) to Fred Hayes (Housing and Home Finance Agency), December 1962Google Scholar, DHEW Microfilm, Roll 25, Kennedy Library, Boston.

41 British Institute of Public Opinion, The Beveridge Report and the Public (London: British Institute of Public Opinion, 1943), 4, 8Google Scholar.

42 Ministry of Information (MOI), “Home Intelligence Special Report: Public Reaction to the White Paper on a National Health Service,” March 14, 1944Google Scholar, Public Record Office (PRO), INF 1/293; Mass Observation Archive (MO), “Interim Report on Feelings about a State Medical Service,” September 27, 1943, FR 1921; “Report on Public Attitudes to State Medicine,” October 8, 1943, MO, FR 1921, 43–56; Gallup, George, ed., The Gallup International Public Opinion Polls, Great Britain 1937–75 (New York: Random House, 1976), 130–31Google Scholar.

43 Henry Willink to Member of Parliament Cobb, November 11, 1944, PRO, MH 80/27; Minutes, first meeting with small committee of the medical profession, May 24, 1943, PRO, MH 80/26; “Universality” (probably written during the winter of 1943–44), PRO, MH 80/27.

44 Maude, John to minister of health, “NHS: Private Treatment by Doctors in the Public Service,” September 7, 1943Google Scholar, PRO, MH 80/26; Maude, J., “Appendix II: Note on a General Practice Service,” January 28, 1943, PRO, MH 80/25Google Scholar.

45 “Universality” (fn. 43).

46 Sir George Godber, interview with author, Cambridge, England, December 13, 1986.

47 The weakness of major interest groups in the face of popularly embraced principles seems consistent with the findings of Page, Shapiro, and Dempsey. They suggest that the transmission of interest group claims via television news has a negative effect on public opinion, pushing it in the opposite direction. Faced with this negative response to interest groups, policymakers can be expected not to accord much weight to interest group views in cases of salient issues. Page, Benjamin, Shapiro, Robert, and Dempsey, Glenn, “What Moves Public Opinion,” American Political Science Review 81 (March 1987)CrossRefGoogle Scholar.

48 Kraft, John, “A Study of Attitudes in North Dakota,” April 1963Google Scholar, POF, BOX 104, Kennedy Library, Boston.

49 Labor and Welfare Division of director of the BOB, January 22, 1961, DHEW Microfilm, Roll 24, and Meyer Feldman Papers (Box 27), Kennedy Library, Boston; Memo to Abraham Ribicoff, “Public Health Service: Recommendations for Legislation for Health Benefits for Aged Persons,” December 28, 1960, DHEW Microfilm, Roll 24, Kennedy Library, Boston.

50 DrLarson, Leonard (AMA) and DrAnnis, Edward (AMA), Testimony, U.S. Congress, House Ways and Means Committee, Hearings on HR 4222, 87th Cong., 1st sess., 1961, 1302–3, 1308–9, 1439Google Scholar; Byrnes, John and Alger, Bruce (committee members), Statements, U.S. Congress, House Ways and Means Committee, Hearings on HR 4222, 87th Cong., 1st sess., 1961, 1818, 1824Google Scholar.

51 DrAnnis, Edward (AMA), Testimony, U.S. Congress, House Ways and Means Committee, Hearings on HR 3920, 88th Cong., 1st sess., 1963, 652–53Google Scholar; DrGroner, Frank (AHA), Testimony, U.S. Congress, House Ways and Means Committee, Hearings on HR 4222, 87th Cong., 1st sess., 1961, 250Google Scholar; Curtis, Thomas (committee member), Statement, U.S. Congress, House Ways and Means Committee, Hearings on HR1, 89th Cong., 1st sess., 1961, 404–6Google Scholar.

52 Harris, Richard, A Sacred Trust (New York: New American Library, 1966), 126–28Google Scholar; Curtis (fn. 51), 404–6; DrHoward, Ernest (AMA), Testimony, U.S. Congress, House Ways and Means Committee, Hearings on HR 4222, 87th Cong., 1st sess., 1961, 1436Google Scholar.

53 Hughes, Philip (assistant director for legislative reference, BOB) to Bill Moyers, May 18, 1965, Ex LE/IS1, Box 75, Johnson Library, AustinGoogle Scholar.

54 Ball, Robert to Sidney Saperstein, “Health Insurance Benefits,” January 16, 1961Google Scholar, DHEW Microfilm, Roll 24, Kennedy Library, Boston.

55 Celebrezze (fn. 38), 8–9; Ball, Robert (commissioner of Social Security, HEW), Testimony, U.S. Congress, House Ways and Means Committee, Hearing on HR1, 89th Cong., 1st sess., 1965, 46–47Google Scholar; Mills, Wilbur (committee chairman), Statement, U.S. Congress, House Ways and Means Committee, Hearings on HR1, 89th Cong., 1st sess., 1965, 70–71Google Scholar; Cohen, Wilbur (HEW), Testimony, U.S. Congress, House Ways and Means Committee, Hearings on HR1, 89th Cong., 1st sess., 1965, 68–70Google Scholar, 102–3.

56 Groner (fn. 51), 256–57; Wilbur Cohen to HEW secretary, February 3, 1965, Ex LE/IS1, Box 75, Johnson Library, Austin; Wilbur Cohen to O'Brien, March 16, 1965, March 17, 1965, July 19, 1965, and July 20, 1965, Ex LE/IS1, Box 75, Johnson Library, Austin; Lawrence O'Brien to President Johnson, March 17, 1965, Ex LE/IS1, Box 75, Johnson Library, Austin; Wilbur Cohen to President Johnson, “Summary of Major Provisions of Social Security Amendments of 1965,” March 19,1965, Ex LE/IS1, Box 75, Johnson Library, Austin; Wilbur Cohen to Claude Desautels, July 12, 1965, Ex LE, Box 4, Johnson Library, Austin; Senator Clinton P. Anderson to President Johnson, July 21, 1965, Ex LE/IS1, Box 75, Johnson Library, Austin; Hughes (fn. 53); Ralph Mueller (Executive Office of the President, President's Committee on Consumer Interests) to Esther Peterson, May 5, 1965, Ex LE/IS1, Box 75, Johnson Library, Austin.

57 “Report on Public Attitudes to State Medicine” (fn. 42), 69–71.

58 Memo to secretary of state of Scotland, “NHS,” June 1943, PRO, MH 80/26; Hawton, John, “NHS: Summary of Main Happenings of the Year,” November 1943, PRO, MH 80/26Google Scholar; Maude (fn. 44, “Appendix II”); PRO, MH 80/25; “National Medical Service: Whole-Time v. Part-Time Service,” March 1943, PRO, MH 77/26.

59 “National Medical Service” (fn. 58); Hawton, John, Memo on attitudes of doctors, March 5, 1943, PRO, MH 80/25Google Scholar; Maude, John to G. H. Henderson, April 12, 1943, PRO, MH 80/25Google Scholar.

60 McNicol, N. F., “GP Service: Some Argumentative Points,” February 26, 1943, PRO, MH 80/31Google Scholar; “National Medical Service” (fn. 58); Maude (fn. 44, “NHS”).

61 Minutes of Reconstruction Committee meeting, January 11, 1944, R (44), 4th, PRO, CAB 87/5.

62 Minutes of meeting with representatives of the BMA, May 13, 1946, NHS (46) 30, PRO, MH 80/32; “The Minister's Proposals for a NHS: The [BMA] Negotiating Committee's Observations,” probably mid-January 1946, PRO, MH 80/32.

63 E.g., see Skocpol and Finegold (fn. 10).

64 A June 1943 Gallup poll reported that 70% felt that a “state-run medical service would … be beneficial for the nation”; in a July 1944 poll of public preferences for two alternatives, 55% favored “a publicly run national health service,” while only 32% preferred leaving health care arrangements “as they are.” Gallup (fn. 42), 77, 92; “Public Attitudes to State Medicine” (fn. 42), 29.

65 Ministry of Information (fn. 42). In a July 1944 Gallup poll, 42% felt that voluntary hospitals should be taken over by a government body; 21% preferred to see them become part voluntary and part government, while another 21% favored keeping them entirely voluntary. Gallup (fn. 42), 93.

66 MO, TC, Health, Box 1, File M.

67 “The White Paper Scheme,” February 10, 1944, PRO, MH 80/27.

68 Pater, John, interview with author, Croydon, England, December 16, 1986Google Scholar.

69 Hawton (fn. 58); Letter from Wetenhall, J. P., November 8, 1944, PRO, MH 80/32Google Scholar.

70 Minister to Wetenhall, J. P., probably January or early February 1944, PRO, MH 80/34Google Scholar; minutes of meeting with voluntary hospital representatives, October 5, 1944, NHS (44) 13, and October 17, 1944, NHS (44) 15, PRO, MH 77/30B.

71 Minutes (fn. 70, October 5, 1944).

72 Bevan, Aneurin, “NHS: The Future of the Hospital Services,” October 5, 1945, PRO, CAB 129/3, CP (45) 205Google Scholar; Godber (fn. 46).

73 “Reform of the Voluntary Hospital System,” probably late summer 1945, PRO, MH 80/34; “NHS—Hospital Scheme,” August 1945, PRO, MH 80/29; minutes of cabinet meeting, October 18, 1945, CM (45) 43d, PRO, CAB 128/1.

74 Bevan (fn. 72); Bevan, “NHS: The Hospital Services,” October 16, 1945, CP (45) 231, PRO, CAB 129/3.

75 Bevan (fn. 72); “NHS: Meeting with the Representatives of the Voluntary Hospitals,” February 11, 1946, NHS (46) 23, PRO, MH 80/30; “NHS–Hospital Scheme” (fn. 73).

76 “Trends of Public Opinion on Kennedy Administration,” February–December 1961, RFK files, Attorney General's Correspondence, Box 15, Kennedy Library, Boston; “Notes for Congressional Sessions,” January 17, 1962 (typed in upper corner, “TCS”), POF, Box 50, Kennedy Library, Boston; Harris, Louis, “A Study of the Gubernatorial and Senate Elections in California, Wave II,” December 1961, POF, Box 105Google Scholar, Kennedy Library, Boston; Quayle, Oliver, “Surveys of Public Opinion in New York, California, Oklahoma, Ohio, Indiana, Maryland,” April 1964Google Scholar, CF PR16, Box 80, Johnson Library, Austin. For a more extensive discussion of these presidential polls, see Jacobs (fn. 20). Gallup polls confirmed these findings; see Schlitz (fn. 28), 140, 170; and Erskine (fn. 35), 134.

77 Bell, David to Theodore Sorenson and Meyer Feldman, January 24, 1961Google Scholar, M. Feldman Papers, Box 27, Kennedy Library, Boston; Celebrezze, Anthony (secretary, HEW), Testimony, U.S. Congress, House Ways and Means Committee, Hearings on HR 3920, 88th Cong., 1st sess., 1963, 162Google Scholar; “Reasons Pro and Con of the Use of Private Health Insurance Agencies in the Administration of a Health Insurance Program,” January 4, 1961, DHEW Microfilm, Roll 24, Kennedy Library, Boston; Labor and Welfare Division (fn. 49).

78 Mills (fn. 55), 287; Celebrezze (fn. 38), 7; Cohen, Wilbur to Lawrence O'Brien, March 11, 1965Google Scholar, Ex LE/IS1, Box 75, Johnson Library, Austin.

79 Ball (fn. 54).

80 Mantos, M. to Lawrence O'Brien, September 15, 1964Google Scholar, Mantos File, Box 9, Johnson Library, Austin; Ribicoff, Abraham to President Kennedy, June 2, 1962Google Scholar, POF, Box 79A, and T. Sorenson Papers, Box 36, Kennedy Library, Boston; Cohen, Wilbur to Hirst Sutton, January 7, 1962Google Scholar, DHEW Microfilm, Roll 24, Kennedy Library, Boston.

81 Hughes (fn. 53); Mueller (fn. 56); Samuel Standard (professor of clinical surgery, NYU College of Medicine) to Molinsky, Adam (Robert Kennedy aide), April 7, 1965Google Scholar, RFK Papers, Senate Legislation, Box 69, Kennedy Library, Boston.

82 The Medicare Act initiated an unparalleled postwar expansion of government involvement in health care. Whether measured in terms of budgetary expenditures, services provided, or population covered, the development of American health policy has been—with the exception of Social Security retirement pensions—unprecedented in comparison with other areas of social welfare. See Rodwin, Victor, The Health Planning Predicament (Berkeley: University of California Press, 1984)Google Scholar; de Kervasdoue, Jean, Kimberly, John, and Rod-win, Victor, The End of an Illusion: The Future of Health Policy in Western Industrialized Nations (Berkeley: University of California Press, 1984)Google Scholar.

83 Cohen, Wilbur, quoted in Sheri David, With Dignity: The Search for Medicare and Medicaid (Westport, Conn.: Greenwood Press, 1985), 143Google Scholar.

84 Skocpol and Finegold (fn. 10).

85 Rather than being able to assess their society in terms of two contending classes and of class-specific behavior such as rioting, policymakers have been faced with intense fragmentation created by ethnic and other cleavages. The emergence and operation of liberal democracy has been identified as a major cause of the fragmentation of society and, especially, of the working class. See Poulantzas, Nicos, State, Power, Socialism (London: New Left Books, 1978)Google Scholar; Przeworski, Adam, Capitalism and Social Democracy (Cambridge: Cambridge Univer sity Press, 1986)Google Scholar; and Ginsberg, Benjamin, The Captive Public (New York: Basic Books, 1986)Google Scholar.

86 For a discussion of the development of an American and British public opinion apparatus for tracking public preferences, see Jacobs, Lawrence, “The Recoil Effect: Public Opinion and Policy Making in the U.S. and Britain,” Comparative Politics 24 (January 1992)CrossRefGoogle Scholar.

87 Skocpol and Finegold (fn. 10).

88 Evans, Peter, Rueschemeyer, Dietrich, and Skocpol, Theda, “On the Road toward a More Adequate Understanding of the State,” in Rueschemeyer, Evans, and Skocpol, , eds., Bringing the State Back In (Cambridge: Cambridge University Press, 1985)CrossRefGoogle Scholar.

89 Dahl, Robert, Democracy and Its Critics (New Haven: Yale University Press, 1989)Google Scholar.

90 Pateman, Carole, Participation and Democratic Theory (Cambridge: Cambridge University Press, 1970)CrossRefGoogle Scholar; MacPherson, Crawford B., The Life and Times of Liberal Democracy (New York: Oxford University Press, 1977)Google Scholar.

91 For instance, the impact of public preferences led policymakers in Britain and the U.S. to abandon compromise arrangements; civil servants believed that these compromise arrangements were so faithful to the concerns of producer groups that they would have been an “administrative nightmare” requiring a “Ministry staff of archangels to work.” See Jacobs (fn. 20).