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Reviewed by:
  • Universal Coverage: The Elusive Quest for National Health Insurance
  • Daniel M. Fox
Rick Mayes . Universal Coverage: The Elusive Quest for National Health Insurance. Ann Arbor: University of Michigan Press, 2004. xvi + 207 pp. Ill. $26.95 (paperbound, 0-472-11457-3).

Rick Mayes's study of the history of failure to achieve universal coverage in the United States now has a second chance to command the attention it deserves. Lexington Books published an edition of 300 copies of Mayes's revised University of Virginia dissertation in 2001: no journal reviewed it; libraries purchased 140 copies. An editor at the University of Michigan Press, after reading a synopsis of the dissertation, then approached him about publishing this paperback edition (which was reviewed favorably for the Press by two historians and a political scientist).

According to Mayes, health and pension policies have been "as much an influence on political actors and processes as they are an outcome of them" (p. 5). He describes the influence and interrelationships of Social Security pensions, policy incentives for employers to offer health insurance, the passage and implementation of Medicare, the effects of efforts to control Medicare costs on the structure of private insurance, and the effects of the history of these policies on the failure to achieve universal coverage in the Clinton administration. Mayes adduces compelling data and analyzes them in lucid prose.

This book belongs to the recent literature testing and elaborating the political science theory of "path dependency." Proponents of this theory use history ("paths") to explain why some events occur while others do not. Many historians will appreciate the focus of scholars who embrace path dependency on the [End Page 852] resonance of past events in later times. Some, however, will complain that path dependency is conducive to determinism and presentism: that is, to ignoring the power of contingency in history, and to assuming that historical questions emerge from current events. Mayes is, however, a supple theorist. He avoids using jargon as a substitute for evidence that contradicts the dependency of policymakers on the paths he discerns. More important, he emphasizes the importance of contingency and the skills of individual politicians in combination with path dependency when he recapitulates the argument of the book (pp. 144–45).

Moreover, Mayes's systematic approach to analyzing how the history of policy constrains the politics of policymaking yields compelling insights. For example, he explains how increases in the payroll tax for Social Security pensions and Medicare in the late 1960s and early 1970s became an impediment to universal coverage. But he does not overstate his case: in the same chapter he describes how the labor movement, departing from its path of three decades, thwarted incremental expansion in coverage in the mid-1970s in the hope of achieving more substantial reform. Such modesty about the power of theory makes more persuasive Mayes's path-dependent argument that employers embraced managed care in response to costs shifted to them by hospitals after the introduction of prospective payment under Medicare.

In an epilogue written for this edition, Mayes offers a compelling interpretation of the failure of health reform in 1993 and 1994. On the basis of interviews with key participants in the White House and Congress, he describes the "self-imposed alienation of key policy makers in the Clinton administration . . . and the extent to which they later alienated key policy makers both in Congress and the larger health care community" (p. 168). This story may, however, be less an example of path dependency in policy than evidence of the persistence of behavioral norms and expectations among people who hold elected office and the members of their immediate staffs.

Mayes is one of a growing number of political scientists and historians who are revising the history of health policy in the United States. Despite their important contributions, these scholars usually ignore two major influences on the politics of health policy over the past half-century: the growing burden of chronic disease, and advances in medical science and technology. Addressing these influences would help scholars and their readers to understand that, although interests and money are central to the history of health policy, they are never the whole story...

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