The Politics of Health Care Policy: The United States in Comparative Perspective

Carol S. Weissert and William G. Weissert. Governing Health:The Politics of Health Policy, 2d ed. Baltimore: Johns Hopkins Univ. Press, 2002. Pp. 369. $27.50 (paper).

THERE ARE FEW SCHOLARS OF HEALTH CARE POLICY who have not contemplated the irony that the United States, the wealthiest and most powerful country in the world, is the only capitalist democracy without some type of national, public health care system. Over 40 million U.S. residents are currently without access to health care, which translates into nearly one in five families with at least one uninsured member. An equal number of Americans have inadequate health coverage. Individual sickness, or that of an intimate family member without adequate health insurance, is a major source of personal bankruptcy. In addition, many workers remain stuck in uninteresting or dead-end jobs because they are afraid of losing their health insurance should they change work site or state residency (IOM 2002). Unsurprisingly, the uninsured and inadequately insured are more likely to have poor health and to die prematurely than those who are adequately insured. Whether one looks at life expectancy at birth, infant mortality rates, under-five mortality rates, or infants with low birth rate, the United States scores poorly compared to other Organisation for Economic Cooperation and Development (OECD) countries (OECD 2001; U.N. Development Program 2000). The situation is even more puzzling because U.S. residents, like people elsewhere, place a high value upon good health care for those who fall ill and support an active role in providing health care for the sick (ISSP 1992, 1996).

A number of books have appeared in recent years that shed light on this apparent contradiction. Carol and William Weissert's Governing Health:The Politics of Healthy Policy, recently published in a second edition (2002), is an important contribution from a political science perspective. The book describes how governmental institutions both shape the definition of health care problems in the United States and ultimately play a major role in their solutions. The reader will appreciate the in-depth reporting on how health care policies actually get hammered out at the federal level and may be surprised to learn about the extent of change that does take place at the intermediate level of health policy making in the country. The Weisserts nevertheless show that, because of the patterns of federal and state politics, national health reform efforts in the United States are doomed to fail.

Yet there is a limit to what can be gleaned about the national politics of health care from a single study, however thorough it may be. Much can be learned by taking a comparative perspective. The comparative method involves analysis of cross-national similarity and difference across salient variables or dimensions of social policy (Ragin 1987). Canada makes an ideal comparison with the United States because of commonality in regard to frontier heritage, British legacy, federal political system, high degree of economic cooperation in matters of international trade, similar patterns of immigration, and rich ethnic diversity. Indeed, Seymour Martin Lipset (1985) argued that these two "North American cousins" are perhaps the two most similar countries in the world. In at least one crucial aspect, however—namely, in regard to national health care policy—the two countries are notably different. Canada provides all residents, free at the point of delivery, access to medical, hospital, and many other health care services. While not without problems—due to unlimited demand for health services and a limited supply of human resources and advanced technologies (resulting in such problems as waiting lists for some medical specialists and certain surgical procedures)—Canada, like all other advanced capitalist democracies, has developed a national health care system, and the United States has not. How can we explain the outlier status of the United States? Recent political science and sociological literature suggests that the answer is complex, requiring an...