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

In One Nation Uninsured, Jill Quadagno provides a sweeping and detailed account of the U.S. health insurance system's development during the 20th century. Drawing on extensive research of primary sources (including archived documents, written oral histories and interviews), Quadagno challenges the four political theories of the welfare state that are commonly used to explain the lack of national health insurance in the United States and offers compelling evidence for an alternative explanation.

The first explanation for why the United States has no national health insurance is the existence of an antistatist political culture, which tends to lead towards private solutions to public problems. Quadagno argues that although antistatist values have emerged in debates about various national health insurance proposals, it is not clear how these values are translated into policy or why legislation has been enacted that contradicts these values. The second explanation is that the trade unions in United States are relatively weak, particularly compared labor-based political parties in other countries. Yet, as Quadagno notes, in several cases labor unions have mobilized to shape welfare policy.

The third explanation focuses on racial politics. Quadagno provides evidence that during the first half of the 20th century southern Democrats colluded with conservative Republicans to undermine national health insurance proposals. However, she also demonstrates that the ability of southern leaders to shape national welfare policy was weakened during the 1960s. The fourth explanation attributes the lack of national health insurance in the United States to the decentralized structure of the American state. Such a system reifies existing policy and inhibits innovation by creating special interests that pressure politicians at various levels of the government to raise opposition to proposed changes. But Quadagno points out that this perspective does not explain how the interests of various groups are translated into particular political actions.

Quadagno readily acknowledges that these four explanations can be used to understand why specific national health care insurance proposals were defeated. However, they do not provide a comprehensive understanding of national health care insurance debates over the course of the twentieth century. To do that, one has to examine the "persistent threads in the campaign against universal health care." (15) Quadagno reveals those "threads" in chapters 1 through 7 by unraveling the historical fabric that surrounds the ongoing struggle to establish national health care insurance.

Chapter 1 provides a detailed account of how during the first half of the 20th century national health insurance was portrayed by key interest groups as a socialist-inspired plan to undermine American liberties. Chapter 2 documents how the activities of organized labor from the end of World War II until the middle of the 1960s fostered the development of the private health insurance system and promoted disability insurance and Medicare. Chapter 3 details how the sovereignty of private hospitals was undermined during the 1950s and 1960s by court rulings and federal legislation. Chapter 4 focuses on Medicare implementation, which made health care profitable and led to skyrocketing health care costs. Chapter 5 demonstrates how during the 1970s through the 1990s stakeholders were able to fend off national health insurance proposals and federal government attempts to contain costs. In the meantime, according to chapters 6 and 7, corporations used their purchasing power to promote managed care and the position of private insurers as the primary provider of health care insurance was solidified.

Throughout these chapters, Quadagno builds a case for the stakeholder mobilization explanation of why the United States has no national health insurance. She demonstrates how proposals for universal health care coverage were effectively resisted by stakeholders including physicians, businesses and insurers. The power of particular stakeholder groups waxed and waned over time, but all of them were associated with organizations that had a federated structure, which is characterized by national leadership, state level offices and a local network, that enabled the development of grassroots campaigns.

Therefore, any successful reform effort has to involve a coalition...