Politics Over Policy

One Nation, Uninsuredby Jill Quadagno

Oxford Univ. Press. 288p $28

With the publication of One Nation, Uninsured, the Florida State University sociologist Jill Quadagno joins an array of scholars who have sought to account for the failure of national health care in the United States and to explain why we get so little health for our health care expenditure. Classics in this field include Theodore Marmor’s The Politics of Medicare (1973); recent works include Theda Skocpol’s Boomerang: Health Care Reform and the Turn Against Government (1997), Marie Gottschalk’s The Shadow Welfare State: Labor, Business, and the Politics of Health Care in the United States (2000) and Colin Gordon’s Dead on Arrival: The Politics of Health Care in Twentieth-Century America (2003). Quadagno, former president of the American Sociological Association, has written widely on U.S. social policy on aging, welfare and social security. What contribution does this new study of U.S. health care policy make?

Quadagno has digested a great deal of scholarly literature on health care across the social sciences; her rich endnotes will be of interest to those who want to follow particular lines of debate. Unlike Gordon’s Dead on Arrival, One Nation, Uninsured is written for a general audience; it assumes no special background or great familiarity with 20th-century politics. In this sense, the book seems designed with the young college student in mind. Those who do not require capsule histories of Watergate, the Kennedy assassination, the Vietnam War or Reagan’s Iran-Contra scandal will breeze quickly through the one- or two-paragraph narrative treatments on how particular events shaped or altered policy agenda at specific moments. The author provides journalistic sketches and descriptions of key players: Kennedy is handsome and youthful; A.F.L. president George Meany was a burly Irishman from the Bronx, and Walter Reuther of the C.I.O. and U.A.W. president was the redheaded son of German immigrants.

One Nation, Uninsured is especially good at demonstrating the role of mobilization, public relations and lobbying in shaping the outcome of health care reform efforts. Of particular interest are the vivid passages from constituent letters to members of Congress during various battles over health care reform, as well as reflective quotes from interviews with key participants in these struggles. While we often think that top-down mobilization of grass-roots lobbying campaigns is a relatively recent K-Street phenomenon, Quadagno chronicles many cases in which the American Medical Association, hospitals, the insurance industry and pharmaceutical companies strove to mobilize both elite and mass opinion when policy proposals threatened their interests, as well as the sometimes successful efforts of organized labor to counteract the power of these large organizations. Although the A.M.A.’s political clout declined, for reasons the author explains, other large interests continued to shape policy reform.

The ironic result of failed federal proposals for universal health care coverage, she argues, is that in each case, federal action entrenched a private alternative to a public program. Government action created private stakeholders and helped entrench private power. Quadagno traces this argument from the Progressive Era to the present, including the current proliferation of long-term care products. In each case, newly created or strengthened stakeholders (for example, commercial insurers, private H.M.O.’s) resisted efforts to create a government-financed health care system. The antireform coalition changed in composition, but stakeholder mobilization has remained the chief obstacle to national health insurance.

Canada has been wrestling of late with the question of whether comprehensiveness and uniformity in the national regulatory scheme for health care require blanket prohibitions of private health insurance plans, a position the legislative and executive branches have maintained in the face of legal challenge. That such a governmental assertion is virtually unimaginable across the border has prompted a variety of explanations for what seems an exceptional path of political development in the United States. While Quadagno notes the role of anti-statist values, the weakness and weakening role of organized labor, and the role of race and the history of segregation in the United States in shaping health care outcomes, she believes the most important historical constant in the 20th century has been that each attempt to guarantee universal coverage has been resisted by powerful special interests who have used every weapon on hand to keep the financing of health services a private endeavor.

With a dwindling number of employers offering employee health insurance and with decline in retiree benefits, Quadagno asks how to reverse the historical tide and fix the unwieldy and inefficient financing system. The book’s final pages discuss prospects for reform. Quadagno ends on a call to action: she proposes that Medicaid eligibility in each state be based on income rather than family status (42 states exclude childless couples and single adults); that uninsured and privately uninsurable people be allowed to buy into the federal employee plan; and that a stop-loss plan be established so that the federal government would reimburse health plans for a percentage of their catastrophic cases.

There are various obstacles to each of these plans, but the most important one for Quadagno is the creation of political will, which requires organizational strength. In the notable instances when ordinary citizens defeated elite stakeholders, their success was predicated on their organizational capacity. For Quadagno, civil rights activists, trade unions and senior citizens succeeded because they coordinated their efforts through organizations that mirrored the federated structure of the American government. She wants groups seeking health care reform to forge a multi-tiered coalition ranging from the grass roots to the national level. This kind of recipe for disseminating ideas, recruiting members and cultivating political friends inside the government may be somewhat anachronistic in light of what we know about patterns of civic engagement.

Here, other scholars have much to say. Robert Putnam, the author of Bowling Alone, has been documenting the decline of civic engagement and of social capital for a decade, and Theda Skocpol has demonstrated that the era of large-scale, mass-membership organizations in American politics seems to be past. Policy think tanks, lobbying organizations with minimal face-to-face contact among member/contributors and cyberspace networks are not the organizations of old, but will likely figure in any new mobilization efforts.

While many believe that an employment-based health insurance system such as ours rules out universal coverage, Quadagno is not persuaded. There are differing priorities among those who would favor government action to expand the provision of quality health care, she notes, but adds that what unites people is the shared risk of being uninsured at some point in one’s life. Some conversation would have been desirable with recent feminist scholarship on care. This literature tries to introduce into public policy consideration of the fact that caring and being cared for are all parts of the life cycle and that no one is self-sufficient. This care literature looks at ways in which care can become a matter of public concern and assistance instead of being left as the work of women and working-class persons of color in the private sphere. Proponents of better, more accessible and more affordable American health care for all need all the allies, supporting arguments and foot soldiers they can muster.