This essay describes how longstanding conceptions of professionalism in American medical care came under attack in the decades since the enactment of Medicare in 1965 and how the reform strategy and core provisions of the 2010 Affordable Care Act (ACA) illustrate the weakening of those ideas and the institutional practices embodying them.

The opening identifies the dominant role of physicians in American medical care in the two decades after World War II. By the time Medicare was enacted in 1965, associations of American physicians were almost completely in charge of medical education, specialist certification, and the enforcement of professional norms on their members. Who could be a doctor, what education and training would be required, and what collegial oversight was operative was first a professional matter and only secondly implicated the state through malpractice or major corporations via the employment of physicians.

All social inquiry, history included, is both theoretical and comparative. This does not mean the analyst is self-conscious about either the theoretical approach or the comparative methods. But it does imply that there is no escaping a theoretical orientation—the concepts employed, the logic of explanation, the descriptive lens of characterization—and no alternative but to make comparisons over time, over space, or across topics. Both A Political Economy of Medicine by J. Rogers Hollingsworth and Health Policies, Health Politics by Daniel Fox raise questions about how one ought to undertake policy history and the comparison of national systems of medical care.

There has been an unending debate in American historiography about the distinctive features of the ante-bellum South. One widely shared view is that the South, by virtue of its dominant agricultural character, was committed to a set of values “inconsistent with a high rate of industrialization”. Writers in this tradition have assumed that agrarian interests entail an anti-industrial bias. They look upon the civilization of the ante-bellum North as “coarse and materialistic” and that of the South as highly refined and aristocratic. The opposite view is that ante-bellum Southerners were no less commercial capitalists than their Northern brethren. Agrarian capitalism, these critics assume, has conflicts of interest with industrial capitalism, not cultural conflicts. The question this essay seeks to answer is whether Calhoun, admittedly a prominant spokesman of agricultural interests, was thereby committed to either an anti-industrial bias or a conventional capitalist position.

Studies of medical politics usually emphasize one of the following types of inquiries: (a) analyzing the internal politics of medical organizations, as with Oliver Garceau's classic study of the American Medical Association; (b) describing and explaining the roles individual physicians play in the political life of the community as voters, officials, or citizen participants in civic life; or, (c) assessing the impact of medical groups and organizations on public policy, particularly health policy. Harry Eckstein's widely known study of the British Medical Association is primarily a study of the third type, a discussion of the channels of influence, the tactics, and the effectiveness of the BMA in shaping public policy to its ends.

This essay contrasts the careers of Robert Ball and Wilbur Cohen, two American public administrators who have devoted fifty years to America's social insurance institutions, with other types of public actors, especially the in and outer rising spirally across departments, policies and administrations. America's separation of powers and federalism reward with influence those who combine entrepreneurial energy, long-term program commitment, and managerial skill; other political structures provide different patterns of opportunities and constraints. It then applies this perspective to Ball and Cohen's participation in three periods of American social policy history: the formation of federal social insurance policy (1935 to 1950); the expansion period (1950–1970); and the turbulent period of stagflation and fiscal stress (1972 to the present).

Perhaps no single policy topic better illustrates the tensions within American politics at the beginning of a new millennium than does Medicare, the nation's thirty-five year commitment to ensuring senior citizens' financial protection against the costs of acute medical care. Our politics seems nearly overwhelmed by conflicting promises to balance the budget and pay down the national debt, enact tax cuts and protect broadly popular “entitlements.” Medicare, one of the largest of such entitlement programs, has become a lightning rod for conflicts over how to resolve these competing goals. As a result, the nation finds itself in the midst of a bewildering mix of crisis talk, fact throwing and ideological name calling, with all the confusion and distortion one would expect from such a mix.