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Bulletin of the History of Medicine 78.2 (2004) 518-519



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Colin Gordon. Dead on Arrival: The Politics of Health Care in Twentieth-Century America. Politics and Society in Twentieth-Century America. Princeton, N.J.: Princeton University Press, 2003. xiii + 316 pp. $29.95, ÂŁ19.95 (0-691-05806-7).

This history of attempts to reform health care (in 1918, 1935, 1949, 1965, 1971, and 1994) will interest historians across many fields including medicine, and is a must read for medical historians interested in the twentieth century. Colin Gordon begins with the question, "Why, alone among its democratic capitalist peers, does the United States not have national health insurance?" (p. 1). The book is a brilliantly recounted, thoughtful, and persuasive argument, not for simple explanations, but for a complex, on-the-ground discussion of what it was in the United States that made universal health insurance "dead on arrival."

Part of the answer lies in the history of racial politics (segregation) in the United States; Gordon notes, for example, that New Deal social policies of the 1930s left 90 percent of the southern black workforce uncovered. Gender politics are also to the fore: the image of the family unit as a (white) male breadwinner with dependents shaped social insurance policy of all kinds. Organized labor reinforced prevailing patterns of race and gender by buying into a private rather [End Page 518] than public welfare state, thus institutionalizing critical social benefits through business-labor negotiation in the workplace, rather than through government. And where benefits did emerge in the public sector, the instrumental role of Southern Democrats in national policymaking helped to ratify a two-class system of benefits: social insurance for workers, nationally administered, set against means-test welfare provisions with decision-making at the local level. All of these factors were socially divisive. Gordon argues that debates about national health insurance were never about universal coverage in the United States.

Health care also became the domain of multiple, powerful private interests, including insurance corporations, organized medicine, hospital lobbies, and employers, exerting national political clout. These organizations controlled substantial resources, but they also seemed to have a surer grasp of politics than the reformers who fought for national health insurance over the years. The latter were woefully deficient in resources—including money, political connections, and organizational base. Though Gordon is clearly on the side of the reformers whose ideas and research were swept aside time and again, the corporate machine (buttressed by resources and a clever use of advertising) had an admirable understanding of how the American system worked. Thus the majority report of the Committee on the Costs of Medical Care (1932) faded into oblivion, while the views expressed in the minority report became the platform for successful opposition to change. Thus the market approaches of the 1990s were "little more than ideological cover for the efforts of some interests to wrestle resources or political advantage away from others" (p. 259).

Dead on Arrival is impeccably and impressively researched, drawing extensively on governmental and private archives. The history is divided into seven chapters, with an introduction and a conclusion. Gordon has controlled his complicated narrative, with its interweaving themes, by telling the story in chapters based on specific topics. After the first, rather dense chapter, which recounts the familiar history of reform attempts between 1910 and 2000, the book gets into gear with chapters covering the same period on, respectively, the way in which interest-driven policy produced the private welfare state; social insurance and its divisive social implications; the role of socialized medicine in the political culture of debates; the politics of race; patterns of influence in health-care policy; and the role of reformers, disorganized, outmaneuvered, and outspent. This structure works well, producing a cumulative thematic effect.


University of Pennsylvania


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