The hybridized nature of America's health care system: Medicare as a case of both market and public failure

The theoretical perspective of Bozeman's publicness work is used to frame a two-part case study of the health insurance system in the United States. It begins with a historical overview of the incremental changes to the system over the past 70 years, illustrating how competing economic and political authorities have combined to create a uniquely expensive and poorly performing system. The empirical lens then focuses on one component of the US system, the Medicare program for the elderly and disabled. It shows how a fully public system has become increasingly privatized through a series of policy reforms starting in the 1990s. This analysis is timely in light of the recent Affordable Care Act of 2010 and the continuing efforts of the US Congress to limit the growth of entitlements such as Medicare.