Health Security for All: Dreams of Universal Health Care in America (review)

In the past decade there has appeared a virtual cottage industry of books on the many failed attempts to enact national health insurance across the twentieth century. Yet anyone who wonders whether there is anything new that can be said about this issue must read Alan Derickson's marvelous book, Health Security for All. Unlike his predecessors who have focused on the politics of health policymaking, Derickson traces the evolution of a societal ideal—universal coverage—and the ways in which reformers have sought to translate that ideal into a plan of action. Interestingly, the concept of universal health care has not necessarily meant an entitlement to care, nor has it meant government financing of health-care services.

During the Progressive Era, the first proposals for state health insurance promoted by the American Association for Labor Legislation were far from universal. Excluded from the AALL plan were the elderly, the permanently disabled, the self-employed, agricultural laborers, domestic workers, and all irregularly employed 206 workers (a provision that effectively ruled out most women). Not until the 1920s did universalism become an ideal. In that period, elite reformers based in medical and public health schools led the drive to make medical care accessible to everyone. One of the main proponents of universal care was the American Medical Association, which nonetheless rejected the idea that this care would be provided through the government. All efforts to increase the public provision of care, whether through county health centers, health services for mothers and infants, or even visiting nurses, were vehemently opposed by the AMA.

In the 1930s the Committee on the Costs of Medical Care voiced support for the concept of universalism but disagreed on a course of action that would make health care accessible to everyone. Yet it was in this period that the first notion of health care as a social right began to take hold, with organized labor at the forefront of the debate. By the 1940s the concept had coalesced into a proposal that truly would have provided universal health-care access.

The goal of universal entitlement faded from view with the collapse of the health-care rights campaign in the postwar period. Instead, voluntary health plans spread rapidly in the 1940s and 1950s, making it appear that private insurance would eventually cover the entire population. As Derickson aptly points out, the success of the voluntarist approach demobilized the core constituency for a universal public insurance program. Universalism was revived in the early 1970s, and then again in the 1990s when President Clinton proposed his own plan for universal access. By then, however, the political will had dissipated. The result of a century-long debate over universalism has been a residual social-policy model in which the government serves as the last resort for the marginal segments of society.

I laud Derickson's fresh approach to health-policy history with its focus on the diverse visions of how best to provide health protection and the amazing array of plans designed by reformers to reach this goal. Yet his discussion of the varying interpretations of universality would have been strengthened if he had provided more historical context. How did the ideological, political, and economic forces in each period influence the salience of universality and the way it was interpreted by the public?

Is it likely that the United States will ever achieve universal coverage or guarantee universal access to health care? Derickson suggests that universality can be achieved if reformers work to build a mass movement among the uninsured, minority-rights advocates, progressive faith-based organizations, children's advocates, and feminist groups. Such a strategy can succeed only if these various constituencies can agree on specific goals—a task that has proved elusive in the past. Health Security for All provides both a way for reformers to understand these past failed efforts and a blueprint for crafting a message for the future.