Health care policies emerge through complex dialectical relationships. The actors who constitute the medical-industrial-complex—providers, insurers, consumers, and advocacy organizations for these groups—push for the enactment of favored policies and against the creation, implementation, or continuation of disfavored policies and procedures. Existing policies, socioeconomic structures, cultural assumptions, and policy-making processes simultaneously encourage, enable, and guide advocates' actions while limiting and constraining the actions of policy advocates. Eventually, through a great deal of private negotiation and occasional open policy debates, different societies institutionalize particular structural arrangements for funding and delivering health care and legitimize distinctive ideological frameworks and rhetorical strategies. In an important sense these arrangements are accidental. This does not mean that they emerge independent of conscious, concerted thought and action by interest groups. It does ...

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