Read an Excerpt
Dead on Arrival
The Politics of health care in Twentieth-Century America Introduction
Why No National Health Insurance In The United States? WHY, alone among its democratic capitalist peers, does the United States not have national health insurance? This question, or variations of it, has invited a range of replies, some focusing on specific historical episodes, others invoking broad political or cultural or economic explanations for the peculiar trajectory of American social policy. At the same time, the explanatory laundry list is profoundly unsatisfying. Historical accounts often have trouble climbing from narrative to explanation; little of the episodic scholarship on the failure of health reform contributes to our larger sense of the American welfare state and its limits. And theoretical accounts often stumble on the descent to historical context; the debate between state-centered and economic explanations, for example, rests largely on abstractions (capitalism, industrialism, democracy) that are neither unique to the American setting nor offered in such a way that they make sense in specific historical contexts. In explaining this hole in the American welfare state, we must consider both the relative success of other American social programs during the years in which healthinsurance was beating at the door and, at least implicitly, the relative success of health insurance in other national settings. Our understanding of the politics of American health care must explain both the exceptional character of the American welfare state and the distinct trajectory of health policy within it. And we must consider the absence of national health insurance in light of public support for reform. As one observer asks: "In effect a powerful army sits before an undefended goal but fails to move. Why?"
The answer rests on the privileged status enjoyed by economic interests in American politics. In health politics, the nature and the alignment of economic or class interests defy easy theoretical categorization. In some respects, the health debate reflects the larger confrontation between labor and capital: employers and insurers have drawn on their control over private investment and economic growth and their command of day-to-day political resources to shape public policy. At the same time, the uneasy relationship between health provision and private production has often confounded expectations and found labor clamoring for private coverage or employers looking to public solutions. In turn, doctors-the most prominent "health interest"-derive their status less from control over "production" than from their social origins, professional training, professional organization, and impressive command of political resources. And attention to conventional class forces tends to obscure the reasons why the United States is alone among its democratic capitalist peers in resisting national health care. For these reasons, I trace the influence of doctors, employers, insurers, and others less as structural interests whose mere presence discourages reform than as instrumental interests whose political stakes and political clout (vis-à-vis the state or each other) are unique to the American setting. The clout of private interests has been magnified in health politics-the only arena of social provision in which private providers, private consumers, and private intermediaries were well ensconced before national reforms were contemplated. This circumstance exaggerated the influence of economic interests and their stakes in reform. The ability and willingness of economic interests to shape health policy eroded an already fragile sense of universal social provision and encouraged the growth of private, employment-based benefits as an alternative. Such alternatives, in turn, reflected and reinforced long-standing patterns of racial and sexual discrimination in such a way that, over time, even reformers rarely challenged the family-wage or Jim Crow premises of private and public social policy. I am interested, in this sense, both in the influence of health interests over the course of the twentieth century and in the consequences of that influence in public and private patterns of health provision, the politics and political culture of health policy, and the broader limits and dilemmas of the American welfare state.
Competing Explanations
Some explanations for American health policy tackle the "why no health insurance" question head on; others collapse health policy into the larger development of the American welfare state; still others offer essentially descriptive explanations in the course of narrating a particular episode or debate. These explanations, in turn, employ a variety of comparative, narrative, and theoretical approaches: some draw loosely on the theoretical literature in order to make sense of historical events; others draw loosely on the historical literature in order to advance theoretical claims about American political development. My own interests and purposes lie somewhere in between. I recognize the importance of building theoretical bridges between academic disciplines and across national boundaries, but I also recognize the difficulty of fitting a past reconstructed from primary sources into neat theoretical boxes. In exploring this scholarship, I am less interested in building up and knocking down straw figures than in scavenging for insights and suggesting the constraints and limits of other explanations. Broadly speaking, these explanations fall into three categories, each of which-in its own way-touches upon the particular absence of health insurance and the broader exceptionalism of the American experience.
The Liberal or Pluralist View
Perhaps the most persistent explanation for health care exceptionalism is the liberal or pluralist view. In this view, the welfare state is a response to the demographic, economic, and political demands of industrialization-reflecting not the demands of labor or capital, but a brokered consensus. This view attributes the failures of health reform in the United States to a popular or cultural faith in private solutions and a corresponding distrust of "radical" political solutions. The United States lacks national health insurance, as Eli Ginzburg argues, because such a policy "runs counter to long-standing American attitudes towards government and deep-seated beliefs ... in the efficacy of market solutions to social problems." In contrast to Britain and Canada and others, the United States boasts "a more fragmented polity, a fluid class structure, and a narrower range of ideological debate." Such explanations generally assume that the American people were naturally receptive to the arguments made by opponents and naturally leery of those made by reformers. As Daniel Fox argues, the latter undermined their chances by refusing to compromise on "practical" or piecemeal reforms and polarizing the debate in such a way that "arguments about proper policy were conducted as holy wars." And such explanations generally dismiss the "why no national health insurance" question as irrelevant or ahistorical, preferring instead to focus on the incremental reforms enacted in its place.
There are a number of problems with this view. It often takes for granted the causal importance of ideas and language. Although charges of socialized medicine and the like shaped and chilled social policy debates, scholars too often exaggerate the sincerity of such ideas, underplay the ways in which they were contested, and ignore the ways in which opponents of reform were able to turn liberal politics to conservative ends. Indeed, the American welfare state has been constructed on quite elastic cultural grounds: much of our current policy would be considered beyond the pale by nineteenth-century standards, just as the contemporary backlash might seem an unusual retreat from the vantage of 1948 or 1968. Reliance on "liberal values" to explain the absence of national health insurance cannot account for either the parallel success of other social programs or the failure of health insurance despite persistent popular support. Finally, this view is largely indifferent to the material advantages and political institutions that privilege some ideas over others. Other countries with professional medical associations and liberal political cultures, after all, emerged from the middle years of the twentieth century with some form of national health insurance. The influence of the American Medical Association (AMA) and others in the American setting reflected not the natural resonance of their message but the immense resources that they brought to bear on politics and public debate.
The Institutionalist View
A state-centered or institutional account has recast our understanding of American exceptionalism by focusing on the autonomy and capacity of the state. Recognizing that American welfare policy diverged from that of its democratic peers despite common intellectual traditions and the shared experience of industrialization, the institutional account turns its attention to differences in political structure-arguing, most broadly, that the weakness of national political institutions and the absence of programmatic party competition after 1896 made it impossible for reformers to transform a relatively generous Civil War pension system into a lasting welfare state. This institutional vacuum invited private alternatives and enabled conservatives to use both a fragmented state and its attendant political culture to frustrate reform. Although this scholarship has focused on programs other than health policy, its implications for our understanding of the latter are clear: institutions matter, and the trajectory of social reform will usually reflect the capacity of those institutions to accommodate new demands. National health insurance, in this view, made little headway because "American political institutions are structurally biased against this kind of comprehensive reform."
This view too has a number of problems. Most important, it dismisses or distorts the influence of economic interests. In part, this reflects an explanatory strategy that combines a devastating critique of crude Marxist state theory with an uncritical deference to traditional political history. In part, this reflects an assumption that elements of political or institutional weakness are static background conditions-and not themselves consequences of the efforts of economic interests to shape or limit state power. And in part, this reflects an eagerness to interpret frustration with political outcomes as evidence of the independence or autonomy of the state-rather than as a reflection of the diverse and often contradictory political demands made by different economic interests. Eagerness to "bring the state back in" is often accompanied by a tendency to usher all other factors out-a tactic that confuses the insight that "institutions matter" with the implausibility that "only institutions matter." Institutionalists have accordingly retreated from a state-centered focus on administrative capacities to a broader, polity-centered consideration of the capacities of both state institutions and political interests. But such assessments typically consider economic interests alongside all other potential political actors without any allowance for their disproportionate stake in political outcomes or their disproportionate command of political resources.
In turn, the institutionalist account underplays the influence of race and gender, and accommodates only their institutional reflections (the relative clout of women's organizations or the unusual congressional clout of southern Democrats, for example). Generally, this view acknowledges the important fact that some women worked for, and others were the target of, maternal health programs, but overlooks the ways in which private and public family-wage assumptions shaped the form and function and legitimacy of all aspects of social provision. Distinctions between deserving and undeserving recipients fragmented any sense of universalism even as they sought to create an entering wedge for state welfare. And the confinement of health care to either private consumption or workplace provision marked less an institutional distinction between public and private responsibility than the prevailing assumption that dependency on the state was a temporary interruption of, or unhappy alternative to, dependence on men. Similarly, racial assumptions and interests were far more pervasive than the influence of southerners in Congress or the Democratic Party. While Southerners ensured that federal social policy not trespass on the deeply racialized political economy of the South, the construction of the "deserving citizen" as a white male industrial worker was rooted in ideas and practices reaching far beyond sectional politics.
Finally, the institutional account is peculiarly ill equipped to explain the divergent paths of health insurance and the other Social Security programs. In terms of raw administrative capacity (especially between 1935 and 1950), the employment-based programs that succeeded (pensions and unemployment insurance) effectively started from scratch, while the program that failed (health insurance) rested on a substantial and diverse foundation of private and public expenditures and programs (including the Veterans' Administration, the Children's Bureau, and extensive public health programs). Economic interests were willing to accommodate the socialization of pensions and unemployment insurance in 1935 but proved unwilling, largely because both private provision and private financing were at stake, to do the same for health insurance. The absence of national health insurance, in short, is precisely opposite the result one would expect from state-centered explanation of the late bloom of American social policy.
The Radical View
Radical scholars have explained American health policy (or its absence) as a reflection of class politics, stressing both the influence of economic interests and the relative weakness of the working class. In some versions, health policy simply reflects the instrumental or structural interests of capital, pressing medicine into a for-profit market mold or responding in a Bismarckian fashion to social unrest. In other versions, the United States is portrayed as a social democratic laggard, and the absence of national health insurance as yet another facet of the failure of socialism in the American setting. Such accounts typically incorporate a particularly damning portrait of both the AMA and the repressive liberalism of American political culture. In sharp contrast to the liberal view, radical scholars argue that politics have frustrated, rather than reflected, popular aspirations and values.
(Continues...)
Excerpted from Dead on Arrival by Colin Gordon Copyright © 2003 by Princeton University Press. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
