Parting at the Crossroads: The Emergence of Health Insurance in the United States and Canada (review)

Antonia Maioni. Parting at the Crossroads: The Emergence of Health Insurance in the United States and Canada. Princeton Studies in American Politics: Historical, International, and Comparative Perspectives. Princeton: Princeton University Press, 1998. xiv + 205 pp. $37.50.

This revised dissertation is a comparative study of the influence of political institutions on policy to finance health care in Canada and the United States. Maioni's principal finding is informative: Canada's "federal structure and parliamentary institutions . . . encouraged the formation of a social-democratic third party and enhanced its efficacy in promoting health policy reform" (p. 6).

Although Maioni insists that her book is original in both theory and method, she offers instead yet another pluralist history of health policy. According to pluralists in history and other social sciences, new health policy is made as a result of conflict among interest groups and advocates that is mediated through political parties. Maioni cites publications by scholars who pursue alternative approaches to health policy, but she does not address their arguments. She ignores or addresses incompletely four issues in the contemporary history of health policy that cannot easily be subsumed under a pluralist interpretation.

The first issue is the assumption that subsidies for biomedical research would result in more effective health services and better health status for populations. Between the 1940s and 1980s many persons in the United States, of a variety of interests and both major parties, shared this assumption. Policymakers in other industrial countries during these years, including Canada perhaps, either accorded lower practical value to biomedical research or used the findings of research paid for by taxpayers in the United States to improve the effectiveness of the health care they subsidized. As a result, funding for biomedical research has been a significant cost of health services only in the United States.

The second issue is particular to the United States, where tax preferences for health insurance have been more important for private-sector employers and employees than proposals for national health insurance. Even when national leaders of labor unions advocated federal legislation for health insurance, leaders of most of the locals on which their power depended regarded health insurance as a matter for collective bargaining. Federal health insurance for the elderly under Social Security became law in 1965 largely because organized labor could not bargain effectively for health insurance for retirees. By defining health insurance as direct subsidy, Maioni misses a significant arena of policy debate.

Third, Maioni has a paragraph comparing the history of U.S. states with that of the provinces of Canada (pp. 160-61), but she ignores the paradox of modern federalism in the United States: centralization has led to improvement in the accountability and capacity of state and local government. The political pressures and regulations that accompany centralization have made government in the states more representative and effective. Did centralization have different or similar effects in Canada?

Finally, like many other pluralists, Maioni ignores the consequences for policy of the increasing burden of chronic degenerative disease. Until recently, policy for organizing and financing health care in every country accorded priority to treating acute episodes of illness. During the past generation, however, each country has revised its health policy to accord higher priority to preventing or postponing the disabling effects of chronic disease. These revisions occur in the context of policy to assure the adequacy of incomes, housing, and social services. Comparative historians of recent health policy ignore relevant data if, like Maioni, they study only the organization and financing of medical and related services.

Maioni and the theorists with whom she identifies in political science and sociology insist that institutions and their history deserve greater attention. Their theorizing, however, is often inconsistent with the historical data they choose to analyze.

Daniel M. Fox
Milbank Memorial Fund

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