Health, health care, and incompletely theorized agreements: a normative theory of health policy decision making.

The years 2003-2004 marked the tenth anniversary of the rapid rise and demise of the Clinton administration's health reform efforts. Health reform may again be a political issue in the 2008 congressional and presidential elections. However, analysts still disagree over why large-scale health reform efforts continue to fail in the American political landscape. This article presents a normative theory for analyzing federal health policy decision making in the United States. This theory states that values and norms, particularly their level of generality, and the social agreement or lack thereof around them have a central role in understanding health policy reform. This theory does not attempt to arrive at a single unified framework for explaining health policy reform, and it recognizes the complementary roles of political science and economic explanations. Nonetheless, it argues that unarticulated values and norms have a critical role to play in health-policy making and reform; this role has been inadequately studied and has lacked a theoretical framework. Within this perspective, this article argues that policy goals, which require individuals to make financial commitments (e.g., tax contributions) in the form of redistributing resources for implementation (e.g., universal health insurance), should be analyzed within a normative framework that evaluates individuals' ethical commitments to making such sacrifices that are beyond their self-interest. The distribution of pub-lic moral norms, their degree of internalization, and the social consensus, or lack thereof, that applies to them must be objects of study in the effort to better understand health policy reform. By emphasizing these factors, this approach offers findings distinct from those provided by existing analyses, and the article concludes with prescriptions for future health reform efforts.