Although sociological definitions of the welfare state include health care within the scope of its functions, empirical scholarship in the field rarely considers health policy topics, and theories of the welfare state ignore health care almost entirely. Conversely, most health policy research does not take account of social science scholarship on the state. My dissertation seeks to redress these omissions through a comparative study of HIV/AIDS policies in the United States and the United Kingdom. HIV/AIDS is a uniquely revealing topic through which to join health policy concerns and welfare state theory because the continually changing epidemiology of HIV generates a constant flow of new challenges to be addressed by contemporary, evolving welfare states. Prior research on HIV/AIDS policy has focused on two types of factors that account for delays and gaps in national responses to the epidemic: cultural biases against the groups most heavily affected, and neoliberal economic approaches that avoid using public expenditures to address social problems. By situating policy-making in response to HIV/AIDS as a problem of social provision and state formation, my research moves beyond these explanations of what did not happen to explain the timing and content of the policies that were enacted.

This dissertation specifically addresses the following puzzle: why have two culturally, politically, and economically similar welfare states responded to similar challenges posed by HIV and AIDS in such different ways? Several differences are particularly notable. On one hand, Britain’s initial national-level response to the epidemic was earlier and more coordinated despite a more severe epidemic in the U.S. In addition, the U.K. has produced a more proactive prevention strategy to address its relatively smaller and more recent problem of HIV in minority communities. On the other hand, dedicated programs developed specifically to deal with HIV/AIDS were phased out in the U.K. by the mid-1990s but have continued to thrive in the U.S. In order to understand these distinct national trajectories, my dissertation first reconstructs the history of policy activity around HIV/AIDS since the early 1990s by drawing on news reports, legislative records, and policy timelines produced by advocacy organizations. It then draws on two additional sources of data to explain cross-national policy variation: sixty-seven original key informant interviews with individuals who have been involved in HIV/AIDS policy-making, and a variety of archived government and advocacy documents from critical policy-making moments.

This research reveals four interlocking dynamics that together explain the differences between these national trajectories of action on HIV/AIDS over the past quarter century. First, HIV/AIDS policies have been shaped by distinct national structures of health care, public health, and medical research. Policy solutions have been designed to operate within the constraints of existing institutions or to ameliorate the limitations of these systems. In so doing, HIV/AIDS policy has also been an active driver of change within welfare state structures. Second, very different relationships between politics and policy have steered national responses to HIV/AIDS in divergent directions: British politicians have consistently distanced themselves from HIV/AIDS issues by delegating policy decisions to experts, whereas American politicians have maintained a hands-on approach to HIV/AIDS policy choices. Third, the mobilization capacities of the social groups most at risk for HIV have played an important role: policy has been most responsive to the needs of people with HIV when they possess sufficient social resources to mobilize a strong, national advocacy campaign. Finally, strategies and outcomes have been strongly influenced by circulating discourses about the epidemic and the social groups most affected by it. In particular, policy-making has alternately been shaped by the association of HIV/AIDS with marginalized ‘others’, and by the fear that it might pose a significant threat to the public at large.

By widening the empirical scope of welfare state scholarship to consider an important contemporary health issue and focusing on the underlying processes that shape the policy response, my dissertation makes two central contributions. First, it points to a reformulated welfare state theory that moves beyond issues of employment and economic distribution to understand the patterns and processes through which governments address a broader range of social welfare issues, including health care. Second, it re-figures health policy as an aspect of state social provision, influenced by politics, culture, resources, and institutions in processes akin to those at work in other arenas of the welfare state.