Beyond interests and institutions: US health policy reform and the surprising silence of big business.

ABSTRACT

Interest-based arguments do not provide satisfying explanations for the surprising reticence of major US employers to take a more active role in the debate surrounding the 2010 Patient Protection and Affordable Care Act (ACA). Through focused comparison with the Bismarckian systems of France and Germany, on the one hand, and with the 1950s and 1960s in the United States, on the other, this article concludes that while institutional elements do account for some of the observed behavior of big business, a necessary complement to this is a fuller understanding of the historically determined legitimating ideology of US firms. From the era of the "corporate commonwealth," US business inherited the principles of private welfare provision and of resistance to any expansion of government control. Once complementary, these principles are now mutually exclusive employer-provided health insurance increasingly is possible only at the cost of ever-increasing government subsidy and regulation. Paralyzed by the uncertainty that followed from this clash of legitimate ideas, major employers found themselves unable to take a coherent and unified stand for or against the law. As a consequence, they failed either to oppose it successfully or to secure modifications to it that would have been useful to them.