Health Care for Some: Rights and Rationing in the United States since 1930 by Beatrix Hoffman (review)

In the United States, health care access has never been a right of citizenship. Rather than being a right, medical care is a commodity accessible only to those with an ability to pay. Rationing, in fact, has been a fundamental component of the system since the Depression era. In Health Care for Some, Beatrix Hoffman makes a strong case for this provocative argument, supported by a detailed examination of Americans’ experiences coping with unequal access to health care. Arguing that rationing has been a fundamental component of the system since the Depression era, she traces the efforts and failures of various administrations–from Franklin Delano Roosevelt to Barack Obama–to embrace universality as a core premise of health policy.

Examining several key points in health policy change, she breaks up the last 80 years of US history into four phases. The first phase covers the Great Depression/New Deal and the failure of policy makers to include health security as a part of the new social security system. The second phase looks at efforts to provide publically funded health care over the course of the Second World War and how this influenced hospital construction and funding in the postwar years, with the concomitant dramatic growth of private health insurance schemes. The third phase traces the expansion of entitlements to care achieved by Lyndon Johnson’s Great Society initiative as well as by ongoing civil, labour, and women’s rights movements active between 1965 and 1980. Finally, the period from 1981 to 2008 saw two decades of system crisis with health management organizations (HMOs), implementing cost controls, and limiting service choice. Over this period, the numbers of uninsured Americans rose dramatically, putting stress on resources such as hospital emergency departments. The book concludes with the struggle to implement “Obamacare” in 2010.¹

Hoffman argues that piecemeal policy responses to problems with service coverage and care provision resulted in a uniquely American approach to health service rationing, which offered up very different levels of care to Americans according to their race, class, gender, age, region, and many other factors. Thus, while rationing in the United States was largely economic, based on the ability to pay, it was also rationed by factors such as geography since some health care facilities had strict residency requirements. The health system evolved unevenly and saw unequal distribution of facilities and personnel throughout the country. It was rationed by age in the case of Medicare and lesser-known programs such as the State Children’s Health Insurance Programs, which covered only the elderly and the very young and contained various restrictions. It rationed by type of insurance coverage, especially in the era of the HMO, which limited benefits and choice of doctor and hospital. And even in some of the most vulnerable populations, the Medicaid system rationed by parental status, as childless individuals were often excluded, including for many years most able-bodied men (134–5).

Rationing could also be more overtly and problematically discriminatory. It could be racial when it was used to build and support the operations of segregated hospitals in the South with support from the Hill-Burton Act. Health insurance coverage was highly gendered for most of this period. Private insurers successfully argued for decades that pregnancy and childbirth constituted a “moral hazard” (one could not take out health insurance with the intention of using it, as with planned pregnancies). Thus, until the Pregnancy Discrimination Act was passed in 1978, most American women, including entire sectors of female workers, could not access even employer-sponsored health insurance included such comprehensive coverage.²

As she explores the various contours and manifestations of American health care rationing, Hoffman points to the many shortcomings of private insurance, showing how companies routinely cut off coverage to individuals who looked like bad risks, targeting populations that would be least likely to use the services. While social movements, activists, and pressure groups...