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This chapter surveys the strategies, tactics, and results of US efforts to change health care policy. It begins by discussing the international health policy agenda in the mid-1990s. It identifies American intellectual trends at the time and how they related to international discourse. It then raises some doubts about how accurately the discourse in the United States and abroad represented practice. Next, it reviews what happened in the United States between 1996 and 2005. For a short time, “market” approaches seemed to be improving the rationality and performance of American health care. Yet that pattern soon reversed, and even when there were savings, they did not work in the way the rhetoric of the time suggested.

This chapter provides a narrative of the complex origins of the American Exceptionalism in health care and the main impediments to the realization of health care as a social right afforded to all Americans. As the chapter discusses, at the heart of American Exceptionalism in health care is “The Great Unsustainable Compromise”, that is, a fragmented mixed-public and private system of health care finance and delivery that has been built around a subsidized employment-based insurance system with selective entitlements to health care for the poor and aged. After tracing the development of the Great Unsustainable Compromise from the demise of the Truman Plan in the late 1940's at the behest of the American Medical Association through the enactment of the Medicare and Medicaid entitlements in 1965, the chapter explains the seeds of its demise and its gradually unraveling over the final decades of the 20th century. In its concluding section, the chapter advances the arguments for the inevitability of the evolvement of the health care system to a publicly financed universal entitlement to comprehensive health care as a social right of citizenship.

This chapter suggests that although the casual observer may see that the American health care system is fragmented and market driven, the underlying reality is that it is also highly regulated. Just as in the United Kingdom, in the United States there is a complex, overlapping web of regulating agencies that make crucial decisions in perpetuating the status quo, promulgating change, and incentivizing certain activities and priorities. According to a newspaper, “unlike some other nations … the United States has no federal agency charged with hospital oversight. Instead, it relies on a patchwork of state health departments and a nonprofit group called the Joint Commission that sets basic quality standards for the nation.”

This chapter discusses the ethical issues raised by the documentary film Worlds Apart (2003). The film tells the story of four culturally diverse patients and families faced with critical medical decisions as they navigate the American health care system. Shot in patients' homes, neighborhoods, places of worship, and hospital wards, Worlds Apart provides a penetrating look both at the patient's culture and the culture of medicine. The chapter focuses on a segment showing the dilemma of a young Lao-American woman, Bouphet Chitsena, who is caught between the strong beliefs of her mother and the recommendations of her doctors regarding her four-year-old daughter, Justine, who has an atrial septal defect (ASD; a hole in the muscular wall between the two atria in her heart). The doctors believe it should be surgically repaired, but Bouphet's mother, Thn Chitsena, is opposed to the operation—an opposition based in the family's strong cultural beliefs and traditional healing practices as members of Khmu, an ethnic group in Southeast Asia with a mistrust of Western medicine.