ABSTRACT
This chapter explores first what happened to the idea of Medicare as the first step to universal health insurance and therefore what conceptions of social insurance are available to bolster the program as it is and as it might be expanded. It tries to understand how and why the development of procompetitive ideas for public policy came to play such an important role in Medicare debates during the last half of the 1990s. Medicare's philosophical underpinnings—to the extent they were clear in 1965—were largely negative, specification of what Medicare was not rather than what its aims and methods fully entailed. The special circumstances of Medicare's enactment further undermined the staying power that social insurance principles have displayed, for example, in retirement pensions. The hopes of some of the procompetitive advocates—of either consumer sovereignty or organizational reform—were a combination of universal coverage and competitive conditions in the pricing and delivery of medical care.
