Enterprise & Society 5.1 (2004) 173-175
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Colin Gordon. Dead on Arrival: The Politics of Health Care in Twentieth-Century America. Princeton, N.J.: Princeton University Press, 2003. xiii + 316 pp. ISBN 0-691-05806-7, $29.95.
Colin Gordon's new book Dead on Arrival: The Politics of Health Care in Twentieth-Century America is a welcome addition to a large literature on the modern United States medical system. It is a truism that despite the trillion dollars (13 percent of Gross Domestic Product) that the U.S. spends on health care, forty million Americans are uninsured. Gordon's book is not a prescription for what might be done about this situation. Rather, his aim is more modest but also more effective: to analyze the politics of why America, alone of all the developed nations, has no compulsory health coverage. Indeed, his introductory chapter is entitled, "Why No National Health Insurance in the United States?"
Gordon shows that this chaos was not the result of amorphous "objective conditions" (a phrase beloved by the Left), but rather the direct outcome of political choices made at specific points during the last century, choices determined by economic interests but also by the political facts of race and gender. Changing political coalitions combined to oppose any attempt at reform, with successive failures in 1918, 1935, 1949, 1965, 1971, and 1994. Gordon's two key notions to explain this failure are institutional opposition and the rise of voluntarism through private welfare benefits. Gordon also sees that the state is, at all levels, deeply involved in health care provision, [End Page 173] whether through regulation or funding. Despite strident antistate rhetoric by vested interests, the American Medical Association (AMA), private insurers, political conservatives, and competition for government authority or largess have dominated American health politics. The AMA sought regulation to exclude unlicensed practitioners, reformers wanted tax dollars to finance social programs, and medical interests needed subsidies to build medical schools and hospitals.
The politics of opposition were formidable, and for Gordon the AMA is the chief villain. The American Association for Labor Legislation's (AALL) campaign for comprehensive health insurance in 1915-1920 (as part of a wider social insurance package) was largely defeated by the AMA's efforts to taint the AALL proposals with the brush of un-Americanism. At the same time, it exalted the principle of fee-for-service to the status of a Mosaic law. This crude appeal to American exceptionalism was to be a familiar refrain with the particular un-American target changing, from Prussian or Bismarckian socialism in World War I, to British National Insurance in the 1920s and 1930s, and then to fascism in the following decade. The debate could stoop pretty low: the Journal of the American Medical Association went so far as to run a regular letter from London between the wars, under the banner "the evils of medical socialism." This led to serious complaints by the chair of the British Medical Association that these comments were unfair to the point of outright untruth. After 1945 a new demon emerged in Soviet style communism, which remained popular until the 1990s. Even so, the AMA always favored its old shibboleth "socialized" medicine à la the National Health Service or its slight variant, the single-payer system in Canada.
Even the cataclysm of the Depression could not dent the AMA's antagonism to state involvement, but it was not the only political influence against change. Failure to get comprehensive health insurance as part of Roosevelt's New Deal social insurance reforms owes much to the AMA's strident hostility, but also to Southern Democratic politicians' refusal to countenance any benefit to blacks at the expense of white workers, the bedrock of their political support. In essence, this prevented any attempt at reform through to the 1960s. The soft option was to turn to federal subsidies for private insurance, which grew out of the development of Blue Cross and Blue Shield in the 1930s, and hospital building. These are well-rounded arguments, and Gordon also makes...