American public hospitals and health centers are often criticized for their inadequate facilities or for not being patient-centred enough. Financial constraints faced by public institutions are often cited for these impediments, but government regulation also shapes the availability of good health care, with either too much or too little regulation typically impacting disproportionately upon patients whose options are limited by where they live or by the affordability of treatment. Despite the (often undervalued) endeavours of primary health care workers, many activists conclude that the system serves its own ends rather than patients’ needs – or, more polemically, that the ‘medical establishment’ poses a ‘threat to health’, as Ivan Illich famously stated in Limits to Medicine (1976). Conversely, though, health institutions are vital for preserving life and for advancing medical research, spanning a matrix of interpersonal and bureaucratic relationships which, in many ways, reflect broader changes in American society and culture. By addressing these divergent perspectives, the five authors of this section explore the politics undergirding the administration of public health institutions in terms of capacity, finances and regulation, while also reflecting historically on public–private institutional relationships, uneven efforts by authorities to tackle racial segregation in hospitals during the postwar years, and the challenges faced by the Veterans Administration in recognizing and caring for the needs of veterans facing adverse mental health experiences arising from their active service.

In assessing the role and scope of health institutions it is tempting to focus on the pace of change and technological innovations since World War II. Developments in tomography in the late 1970s and the emergence of mobile health services (or mHealth) in the 2010s, to take two examples, have offered new horizons for preserving lives. But whether we see such technological developments as complementing or straining the interpersonal bond between doctors and patients, we should remember that ‘old forms and practices coexist alongside the new’, as the 2000 volume Institutional Change and Healthcare Organizations reminds us. Sometimes owners and governing bodies are resistant to change or their organizations lack the bureaucratic agility to ensure that when change happens it is in the patients’ interest.