Reforming Medicare: the limited framework of political discourse on equity and economy.

Medicare, the major program that organizes the delivery and financing of health care for the elderly in the United States, is being rapidly and significantly changed in order to bring Federal expenditures for health care under control. Questions of 'equity', 'justice' and 'access to health care' (that have long been associated with liberal ideology) have lost discursive currency within the realm of acceptable political debate that now focuses on 'economy' and the restoration of 'competitive market forces' to the health care industry (a point of view associated with conservative ideology). Pluralistic analyses of American health care policy most often focus on the differences between liberals and conservatives and could only explain the current bipartisan effort to reorganize Medicare as a defeat for liberals and as a vindication for the conservative perspective during a period of economic crisis. This essay develops the alternative point of view that American political debate on health care, among and between liberals and conservatives, has always taken place within a space bracketed by well defined limits established by widespread support for the market model of health care. The strength and dominance of this model that organizes and supports the private production of health care for profit is far more important in explaining the continuity in American health care policy over time and the recent policy adjustments than any examination of ideological differences between political conservatives and liberals. After analyzing the limited framework of debate structured by the market model of health care, this paper critically examines the recent changes in Medicare and challenges the market model on empirical grounds. Finally, the author returns to a discussion of the implications of these changes for equity and justice.