Health Security for All: Dreams of Universal Health Care in America (review)

Why is there no national health insurance in the United States? The answer is that there is national health insurance in the United States and quite a lot of it. The problem lies in the fact that this country has too much health insurance—making our health care system very costly—and too little—limiting access to health care to well over forty million people. Alan Derickson, one of this country's best historians of health care policy, asks the right question in this expert monograph on the idea of access to universal health care in America during the twentieth century. He shows that, although the nation has made periodic surges toward national health insurance, the result has never amounted to universal access. In fact, we have moved further away from this ideal in the last third of the last century.

Derickson surveys the twisting fortunes of the idea of universal health care through time. In the progressive era, labor economists and others with an interest in the terms of the wage bargain tended to dominate the discussion. The result was proposals from groups such as the American Association for Labor Legislation to have the state subsidize health insurance for the working classes. This class-specific formulation of the problem rankled many Americans, including conservative businessmen and upwardly mobile members of labor unions. Derickson perceptively notes that the progressives imported many of their ideas from abroad. At the time, the European welfare state was far from universal in its scope of coverage. Instead it used the state to confer benefits on particular occupational groups.

In the twenties another idea arose that had considerable consequences for the idea of universal access. Using the axiom that if they build it, they'll come, public health reformers touted what Derickson calls a supply side solution to the problem. If there were enough health care facilities, then the problem of access to health would be solved. One problem, of course, was that there were a lot of vagaries concerning who would come, as reflected in the very nature of a country that raised racial and regional barriers to providing services of any sort.

Eventually, the Great Society produced a synthesis of the ideas from the progressive era and the twenties in the form of Medicare and Medicaid. It was health care for those left behind in the tremendous expansion of private health insurance in the postwar era. The federal programs took the specific forms of health benefits for the elderly and for those on welfare. Medicare in particular continued to reflect the progressive era emphasis on the wage bargain in its emphasis on social insurance and payroll taxes, and its passage coincided with an exponential increase in federal money for hospitals, medical schools, medical research and other pieces of what might be called the medical infrastructure.

The problem was that social insurance, which insured workers but not others in the general population, mitigated against the very notion of universal health care. The structure of permissive programs like Medicare helped to raise medical care costs and create a crisis in health care finance. As rising costs became the central problem of medical policy, the issue of universal access tended to be shunted aside, with tragic consequences for those on the edges of American society.

Derickson has written a very short and very heavily footnoted monograph. Toward the end of the book, one page of text calls forth one whole page of notes. Usually one finishes academic monographs of this sort with a sense of relief. In this case, however, I had the feeling that the book was too short. It dwells at considerable length at well-known events, such as the National Health Conference of 1938, and then just races through the period after Medicare, particularly the time between Jimmy Carter and the present. To be sure, Derickson puts new twists on old stories, such as the animosity between the...