Much of the resistance to the Patient Protection and Affordable Care Act signed by President Obama in March 2010 is encapsulated in the claim that it constitutes a “government takeover” of health care. In this as in other arenas, many US citizens indicate that they would rather entrust their welfare to the operations of private economic markets than to decisions made by government.
Because of a combination of economic, social, and legal factors, considerable power over health care has effectively been delegated to medical societies, research organizations, and other institutions, enabling them to function in some respects like government rather than agents in a free market. In particular, the issuance of official statements setting the criteria for the diagnosis and treatment of disease can have much the same effect as the enactment of legislation or promulgation of regulations. In this Commentary, we describe how this “shadow government” evolved and discuss some of the implications of this phenomenon for health policy.