Chronic Politics: Health Care Security from FDR to George W. Bush (review)

Chronic Politics is the story of the federal government's efforts to provide some form of health-care security to most Americans—a story that Philip Funigiello begins on the eve of the New Deal and continues up through the Bush administration's Medicare prescription-drug benefit. There are two tendencies in such broad scholarship: one is to dive deep into some narrow topical crevice in an in-depth exploration of a small aspect of the subject; the other is to glide somewhat superficially over vast stretches of time and subject matter. This volume avoids both tendencies and achieves that pleasing combination of a work that displays both satisfying depth and impressive scope. Funigiello has spent a career as a scholar of health-care policy, and his long years of acquaintance with the topic show in his ability to construct a clear narrative thread through what is, after all, a very complicated policy story.

The author tells a fairly conventional tale here, in which progressive reformers are continually thwarted by the AMA and other forces of conservative resistance—what he calls "the insurance-medical industry complex" (p. 203). The other antiheroes of his story are those political figures whom he describes as "budget-deficit hawks and anti-government ideologues" (p. 303)—for which one can read: Republicans and conservative Democrats.

Funigiello's aim is the rather traditional one of explaining American exceptionalism in health-care financing—that is, why America does not have a system of national health insurance for all its citizens. The short answer is given in the book's title: chronic politics. His larger thesis is that persistent aspects of the American character and political system (individualism, laissez-faire capitalism, federalism, and political partisanship) are in competition with the necessary ethos of pragmatism and community that would be expected to lead to national health insurance. Within the framework of this viewpoint, he does a credible job of surveying the past seventy-plus years of national efforts to craft some satisfactory form of government-sponsored health-care coverage. It is neither the novelty of his thesis, nor the revelation of some new major archival discoveries, that is the real contribution of this work to the literature; rather, it is the wealth of detail and the comprehensive scope of the narrative.

Chronic Politics is an example of traditional political history, focusing on individuals and groups and the political struggles over particular pieces of public policy. In this respect, it is rich with historical detail and strong on narrative rather than being theoretically oriented. The discussion of the rise and fall of the Clinton health-care proposals is particularly clear and easy to follow and represents one of the better short summaries of this episode. On the other hand, the recounting of the Bush prescription-drug-benefit plan seems rather rushed, like something added at the last minute without benefit of the in-depth scholarship evident in the rest of the book.

One can quarrel with minor points here and there, such as the fashionable idea that the proponents of wage-based social insurance in the 1930s were pushing this option as self-serving bureaucratic nest-feathering, rather than as a principled judgment as to what form of social provision best fit the American temperament (p. 43). Funigiello's obvious preference for government-sponsored universal health-care coverage also intrudes into his analysis upon occasion. But overall, the narrative is sound and reliable. Well researched and amply documented, the book also includes a useful bibliographic essay.