Journal of Interdisciplinary History 33.1 (2002) 146-147
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The Wages of Sickness:
The Politics of Health Insurance in Progressive America
The Wages of Sickness: The Politics of Health Insurance in Progressive America. By Beatrix Hoffman (Chapel Hill, University of North Carolina Press, 2001) 261 pp. $39.95 cloth $17.95 paper
The puzzle of American exceptionalism takes many forms. For historians of social policy, the key questions are defined by comparisons with Europe. Why was the United States precocious in providing public education, yet slow in establishing many provisions for workers and the elderly? And, unlike other industrialized nations, why did the United States fail to lay the foundations for a system of universal health coverage?
In The Wages of Sickness, Hoffman asserts that "it could have happened here." Prior to the world war, many states had adopted workmen's compensation and mothers' pensions legislation. A system of health and factory safety regulation was under construction. Momentum, it appeared, was with the advocates of comprehensive social provision. But in Hoffman's analysis, no economic determinism or functional requirements guarantee the completion of a system of social provision. Instead, she explores the coalition politics that promoted and opposed policy initiatives. Insofar as successful policies enlarged their supporting constituency, each battle was potentially a key turning point: "Had they been successful, their plan might have planted the seeds of a full-fledged system of universal health coverage in the United States" (1). But they failed.
Hoffman focuses on the efforts to adopt health insurance in New York State, where bills came before the legislature a number of times and, in 1919, actually passed the state Senate. To explain why health insurance came closer to fruition in New York than in any other state but ultimately failed, she reconstructs the key players and constituencies: progressive reformers, health providers, fraternal insurance orders, commercial insurance corporations, employers, organized labor, and women's associations. In this complex political world, no one interest controlled outcomes; the struggle for health insurance unfolded through [End Page 146] a politics of alliance and persuasion. To explain why "it didn't happen here," she carefully reconstructs the missed opportunities for alliances and the interaction of policy content with coalition building.
Two episodes illustrate the power of this analysis. The first centers on the erosion of the alliance of reformers, employers, and commercial insurers that had supported workmen's compensation legislation. Why did this partnership not extend to health insurance? In the absence of the expensive liability judgments for workplace injuries that had prompted this earlier alliance, business and insurance interests opposed the imposition of further mandates. Policy coalitions turned on specific conjunctures of interest. Still more puzzling is why New York's physicians came to oppose a system of insurance that promised to provide both higher and more predictable incomes for many practitioners. In this regard, the analysis highlights the role of policy entrepreneurs in linking health insurance to the potent opposition of Americanism and Bolshevism in the years after World War I. Acting as a front for commercial insurers, Carleton Babcock of the New York League for Americanism redefined opposition to public insurance as opposition to socialism and the exemplars drawn from a defeated Germany.
Could it have happened here? Hoffman persuasively argues that the conjuncture of health-insurance initiatives with World War I and the Red Scare allowed opponents of reform to construct a broad coalition including physicians and portions of organized labor. Yet the resistance to government intervention in the 1920s—particularly the enforcement of Prohibition and the income tax—suggests deeper currents of resistance to policy expansion. On this score, The Wages of Sickness is a call for more sustained analysis of the opposition to reform in American politics. Just as scholars of American politics at mid-century have begun to reconstruct the origins of the new Right, historians of the progressive era can learn much by looking beyond the advocates of reform to the mobilization of opposition. The premise that it could have happened here can then be...