ONE NATION, UNINSURED
Why the U.S. Has No National Health Insurance
By Jill Quadagno. Oxford Univ. 274 pp. $28
The troubles of the U.S. health care system make front-page news almost every day. As costs rise, employers are cutting back on coverage for employees or offering none at all. State governments say they can't pump more money into Medicaid to pick up the slack, while safety-net hospitals say they're maxed out, too. The result: Tens of millions of Americans cannot afford basic care.
It's a serious problem -- but not, Jill Quadagno reminds us in One Nation, Uninsured, a particularly novel one. On the contrary, similar health care "crises" cropped up repeatedly during the 20th century, always playing out in the same unfulfilling way. First, anxiety over affordable health care leads progressive politicians to push for universal health insurance. Then the campaign fails. Eventually, the private sector reforms itself, but in a limited way that makes the next crisis virtually inevitable.
One Nation, Uninsured attempts to explain why progressives keep losing -- and why, as a result, the United States remains the only industrialized nation without universal health insurance. The question could not be more timely, especially since a battered Democratic Party is now loudly casting about for "big ideas." And although Quadagno's answer is not exactly shocking, her briskly written history offers an excellent primer for anybody interested in picking up the reform banner today.
While acknowledging all the different factors that have blocked universal coverage in the past, Quadagno, a Florida State University sociologist, argues that the most significant obstacle has been the virulent opposition of special interests that profit from existing health care arrangements, however flawed. Different "stakeholders" led the charge against universal coverage in different eras: physicians before the 1970s, insurers and employers afterward. But, Quadagno shows, the campaigns took similar shape -- and produced similar results -- with each new battle. Particularly striking are the parallels between the fight against Harry Truman in the 1940s and the one against Bill Clinton in the 1990s, from the use of congressional investigations to distract the White House to the literal demonizing of individual reform proponents. ("We first thought of making President Truman the devil, but he's too popular," an American Medical Association strategist explained in 1949. "But [a key Truman adviser] is a perfect Devil and we're going to give him the works.")
Although the basic storylines here will be familiar to readers of such books as Paul Starr's Pulitzer Prize-winning The Social Transformation of American Medicine, Quadagno uses the personal recollections of past reformers (collected through oral histories and interviews) to construct a series of fresh, engaging historical narratives. But this approach also leads her to overemphasize the role of special interests -- who, understandably, loom large in the minds of those vanquished by them. A major reason for public ambivalence about the Clinton plan, for example, was middle-class Americans' fear that they would end up with coverage that was either more restrictive or more expensive than the generous, fee-for-service insurance plans that large employers had historically provided for their workers. (Of course, the public failed to realize that employers were already switching to managed care anyway.) While special interests certainly stoked these feelings with their infamous "Harry and Louise" advertisements, they were also playing to a very receptive audience.
Still, it's hard to quibble with Quadagno's thesis too much since, as she shows, virtually every major evolution in the financing of U.S. medical care has occurred only when special interests themselves demanded change -- and even then only in ways that conformed to their ideological and financial preferences. Private insurance began to spread in the 1930s, when hospitals were desperate for paying patients to fill their beds; managed care took off in the 1990s because employers were desperate to control the cost of employee benefits. But each development represented an alternative to proposals for universal health insurance, which, the special interests feared, would encourage government interference in medicine and beyond. (Medicare, the lone success in the campaign for universal coverage, could pass only because private insurance companies had found that insuring retirees was unprofitable and because hospitals figured that a government insurance program was better than nothing.)
Understandably glum about the immediate future, Quadagno suggests that today's reformers concentrate on incremental initiatives identical to the ones Sen. John F. Kerry proposed in the 2004 presidential campaign. But if Quadagno's book teaches anything, it's that such half-measures buy only modest relief and, even then, only for a little while. That's why the more important message of her book is about political strategy. Quadagno notes that in addition to outspending the proponents of universal coverage, special interests have also done a better job of grass-roots organizing (by, for example, using doctors and insurance agents to carry anti-reform messages within communities). And while the opponents of reform have maintained impressive ideological unity, coalitions on the left have frequently splintered. The United Mine Workers and other industrial unions abandoned Truman when they won generous private benefits for their memberships; labor sat out most of the "Clinton-care" fight because it was preoccupied with the North American Free Trade Agreement.
Quadagno's ultimate message seems to be that politics are more important than policy -- that progressives won't achieve universal coverage unless they learn to operate like the special interests of the right. She's probably correct -- which is why her richly constructed history could prove so handy in the months and years to come. *
Jonathan Cohn is a senior editor at the New Republic. He is writing a book about the U.S. health care system.