One Nation Uninsured: Why the U.S. Has No National Health Insurance (review)

The question in Jill Quadagno's subtitle has been addressed by scholars and advocates (and scholars who are also advocates) for almost a century. Most of these authors have attributed the failure to enact national health insurance in the United States to the political behavior of organizations that represent health-care providers, the characteristics of American political institutions, widely shared antipathy to government among Americans, or some combination of these factors. Quadagno criticizes these interpretations. She faults the American people and their leaders because they have "ceded our health care to private interests" (p. 16). Her theme is that the "challenge is not in identifying feasible choices but in mustering the political will" to enact universal coverage (p. 212). She believes that "the public is willing," and that the "time to act is now" (p. 213).

This book has strengths that make it worth reading (though at least three scholarly books published in the last two years address the same subject). Quadagno tells compelling stories about the politics of health policy. Unlike scholars who emphasize attempts to achieve universal coverage, she accords considerable attention to the politics of incremental reform. These reform efforts include the failure of catastrophic insurance under Medicare in the late 1980s, and the controversial introduction of managed care in the 1990s. Quadagno's history of long-term care insurance (LTCI) is the first I know of that is directed at readers who do not specialize in geriatrics or insurance. Unfortunately, she misstates the law about the deductibility of LTCI because she did not follow federal legislation from its introduction to its enactment (p. 197).

This is not an isolated error. Some errors suggest a lack of knowledge about American history and politics: for example, Quadagno believes that states "have the right to nullify federal legislation" (p. 14), that presidents of the United States speak before only one house of Congress (pp. 26, 67), that Chief Justice Charles Evans Hughes became secretary of state in 1937 (p. 29), and that the assassination of the Reverend Martin Luther King occurred in August 1968 (which misses the political significance of its occurrence in April). Other errors suggest unfamiliarity with the history of health policy: examples include claiming that Morris Fishbein was president of the AMA when he was an employee, as editor of its principal journal (pp. 7, 22); identifying the Social Security Board as the organizer of an important conference on health policy in 1938, instead of a federal interagency committee whose members had subcabinet status (p. 25); misidentifying as a physician Michael Davis, one of the first influential health-care administrators and policy analysts who did not have a medical degree (p. 38); confusing Paul Ellwood with his son David, a well-known scholar and policy advisor on social policy (p. 187); and accepting sources that enable her to claim on consecutive pages that the United States had 20,000 and 13,000 hospitals in 1965 (pp. 86, 87).

Quadagno concludes with a program of political mobilization on behalf of national health insurance. Like many of the people she writes about, and most other scholars of the subject, she believes that national health insurance can be enacted following a well-organized campaign. The only campaigns for health insurance that have succeeded in the United States, however, have sought expanded coverage for seniors and children, not universal coverage. The evidence in this book and many others could be interpreted as demonstrating that incremental reform may be the best way to increase access to health care. This evidence also suggests that scholarship about the past does not contribute much that could inform speculation about what combination of events within and outside the United States might precipitate universal coverage.