A Germ Theory for Government
The role of public health in the formation of political orders
Political Orders
Historian Gary Gerstle argues that modern American politics is best understood through the lens of political orders. More than singular politicians, these are decades long shifts in the structure of political life. Orders are frameworks through which Americans understand what their government should do, who it should serve, and what kinds of risks it should help manage.
Political orders are not born overnight, nor are they simply the result of electoral coalitions coming together. Gerstle emphasizes that political orders arise in the aftermath of visible crises (wars, depressions, pandemics) that reveal the inadequacies of the old system and create space for new ideas to take hold. The New Deal order, born from the shocks of the Spanish Flu, WWI, and the Great Depression, redefined government as a proactive guarantor of economic stability and collective security. The Neoliberal order that followed, formed reactively in the economic turmoil of the 1970s, then recast government as a problem to be limited and the market as the impartial tool for distributing goods.
The Germ
Healthcare reform has been an enormous mirror of political orders.
The New Deal order was preceded by a devastating pandemic that exposed structural weaknesses in the nation’s public health system. Then, we invested: Social Security, Public Health Service, NIH, Medicare, Medicaid, and a wave of hospital construction and medical education funding. Healthcare was framed as a public good.
The Neoliberal order was preceded by healthcare cost inflation dramatically outpacing inflation in the greater economy. Then, we disinvested: capped federal spending, squeezed provider payments, limited residency slots, and handed parts of the system over to private equity. Healthcare became a market good. That shift was supported by a famous RAND study extolling the benefits of private insurance.
The Affordable Care Act (ACA), passed in 2010, was the last major attempt at structural healthcare reform and very much a product of a fracturing political order. It sought to simplify and expand coverage while preserving the primacy of private insurance. While the ACA succeeded in expanding coverage to millions, it also entrenched fragmentation and inequities it sought to address. State-led Medicaid expansion, subsidized private plans, and new regulations for providers left gaps in coverage and affordability.
The Infection
Between 2013 and 2015, medical debt overtook non-medical debt in collections for Americans, and since 2010 there have been 130 rural hospitals closed for good. Then, in 2020, COVID-19 layered testing delays, hospital overcrowding, and supply chain breakdowns on top of a healthcare system hemorrhaging trust.
There is no agreement yet on how to reshape healthcare, but there are signals worth paying attention to.
Republican leaders, former champions of free-market healthcare, have embraced insulin price caps and drug price controls. Trump’s proposed pharmaceutical price reforms reflect a populist turn against corporate pricing power. Josh Hawley’s recent op-ed defended Medicaid against proposed cuts, noting specifically how such cuts would harm his constituents in Missouri.
What’s striking to me is how much the political conversation has shifted since the ACA. In 2010, the fight was over the role of government in facilitating access to a market-based system. Today, the fight is increasingly about whether the model itself can deliver basic needs.
These aren’t isolated blips; they point to a shared public anxiety about affordability, fairness, and the ethos of the healthcare system.
What’s Next?
Political orders rise out of crises and instability, and result from the acquiescence of opposing political parties. This resembles sort of a germ theory for government and political orders.
Crisis and instability is the germ. A germ which reorganizes and reshapes political coalitions in response to demands of the new era. The infection is when the ideas and solutions proposed by one-party are adopted by, or infect, the opposition.
There’s good reason to believe we’re currently living through the formation of a new political order. The 2008 financial crisis, COVID, inflation, geopolitical tension could each constitute a destabilizing “germ” on their own. “Infections” are happening, but not necessarily spreading, yet.
The New Deal wasn’t inevitable. The Neoliberal order wasn’t inevitable. Both responded to questions, not just of capacity in government, but imagination for what government can and should do. The same potential exists today, but the next political order is far from clear; the outcomes even less so.
Over the next couple articles, I’ll call out more contradictions muddying the waters on a new political order, what could resolve them, and ultimately, what system I expect to graduate into as a future healthcare provider.