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BOOK REVIEW |
Professor of Social Policy Boston University School of Social Work Boston, MA 02215
One Nation, Uninsured: Why the U.S. Has No National Health Insurance, by Jill Quadagno. Oxford University Press, New York, 2005, 274 pp., $28.00 (cloth).
Jill Quadagno, a long-time student of health and aging policy issues in the United States, has written a thoughtful, accessible, and provocative account of the great social policy nonevent in American political life: the failure to enact national health insurance. Her topic is as fascinating as it is obvious. She seeks to explain why we have not brought about something that: (a) many people believe we should have done, (b) people in most other industrialized nations have done, and (c) we seemed on the verge of actually doing on more than one occasion.
Quadagno adds new currents to these well-navigated health care waters. She directly challenges a major argument in Paul Starr's (1982) classic, The Social Transformation of American Medicine, emphasizes more proximate factors than does Theodore Marmor (1970) in The Politics of Medicare, uses a wider lens than does David Smith (2002) in Entitlement Politics: Medicare and Medicaid, 1995–2001, and places less emphasis on raw ideology than does Joseph White (2003) in False Alarm: Why the Greatest Threat to Social Security and Medicare is the Campaign to "Save" Them.
Furthermore, Quadagno has written a book aimed at two divergent audiences: scholars and their students interested in understanding the ins and outs of social policy and a broader lay public interested in being better informed about why the United States has not achieved a policy goal that she believes to be of utmost importance to the nation's health and dignity. The volume should be well received by both audiences, although academics are likely to find the theoretical discussions and conclusions less than convincing, if only because so little direct attention is paid to alternative constructs to the one she ends up favoring. The broader public may glance only in passing at this conceptual material, but it should be well satisfied by the clarity of exposition, the use of often fascinating primary sources, and the author's sense of urgency that is seldom found in scholarly writing.
Overview
The essential organization of One Nation, Uninsured is chronological with thematic overlays. The first chapter traces health policy developments through the end of World War II, and the second chapter takes the story through the mid-1960s and the enactment of Medicare. The three subsequent chapters broadly address implementation issues associated with Medicare's passage. They provide an insightful account of Medicare's role in desegregating hospitals in the South, a profile of the cozy relationships between insurers and hospitals, a detailing of physicians' amazement in seeing how they could (and should!) raise fees, and a review of how escalating concerns about cost containment overwhelmed nascent and promising efforts by Walter Reuther of the United Auto Workers and Senator Edward Kennedy to place national health insurance centrally on the nation's agenda.
The next two chapters bring the story up to the present day. Chapter six provides a vigorous account of how corporate purchasers of health care centrally confronted both providers and the insurance establishment, which appeared to be abetting providers' avarice, noting in particular how the Employee Retirement Income Security Act (ERISA) furthered the development of employer-sponsored health care plans. By the end of the 1990s, the battle is almost entirely on the private side, with emerging alliances of providers and patients resisting the cost and access pressures which employer-sponsored managed care had brought to the health care arena. Yet, chapter seven finds "insurers triumphant" as she traces a series of flawed initiatives, including the Clinton health care proposal, welfare reform, the State Children's Health Care Insurance program, and Medicare+Choice. In Quadagno's estimation, these efforts have failed to bring the nation close to anything approaching universal coverage under a manageable fiscal regimen.
The book's concluding chapter poses the critical question of how the United States might get closer to national health insurance, and Quadagno makes several suggestions toward that end. These include continuing to liberalize Medicaid, a process Colleen Grogan (2005) labels in a somewhat different context, "universalism within targeting"; offering vouchers to individuals above Medicaid cutoffs to buy into the Federal Employees Health Benefits Program; establishing a "stop-loss" or premium rebate pool not unlike what John Kerry proposed in the 2004 election; and/or providing tax credits against the purchase of a private health insurance plan. Finally, Quadagno calls for a three-tiered political coalition, involving a national leadership strategizing group, intermediate groups such as senior citizens' clubs and labor federations, and local chapters to mobilize grassroots activists to engage in social action.
Quadagno uses two theoretical lenses of different magnitude to account for the sad history of national health insurance in the United States. The broader of the two is at the grand theory level—a review of broad theoretical approaches seeking to account for patterns of welfare state development cross-nationally. The second explores developments within Quadagno's grand theory of choice, "stakeholder involvement," centered on the interplay of key actors, interest groups, and other players. The latter approach is clearly the book's dominant one, as Quadagno explores the shifting and evolving role of players critical to health policy developments in the United States. This core material is bookended by consideration of where stakeholder theory should be considered in terms of alternative welfare state constructions: antistatist values, weak labor, racial politics in the South, and state structures and policy legacies.
Stakeholder Politics and National Health Insurance
Quadagno's stakeholder story unfolds in thorough and engaging fashion. The early historical material contrasts the nascent pro-government social policy movement, associated with groups such as the American Association for Labor Legislation, with virulently antigovernment intervention groups, such as the Commission on Costs of Medical Care and the American Medical Association (AMA), which opposed both voluntary (private) and mandatory (government) health insurance proposals. While early Blue Cross actions stabilized fluctuating hospital revenues during and after the Depression, access to health care remained a huge issue, one which served to usher in the Truman national health initiative of the late 1940s. Invoking Red Scare and socialized medicine fears, the AMA led the successful charge against the Truman plan.
Yet, Quadagno argues that by as early as the late 1940s, the AMA was seen in many quarters as overplaying its hand and generating growing levels of distrust about is true motivations. In this context, she introduces one of her key stakeholder arguments, namely, that while the AMA appeared to have won its legislative battle in the Truman era (and earlier during the New Deal), it had done so only because it had the support of powerful allies from the business and insurance industries and from the South. Indeed, much of the book's subsequent material is designed to show that as these erstwhile allies fell away from the AMA cause, the spurious nature of its alleged power revealed itself.
A second stakeholder theme, centering on the role and interests of organized labor, developed towards the end of this period and extended well into the 1960s. As have others (Stevens, 1988; Klein, 2003), Quadagno reviews the surprisingly lukewarm stance much of organized labor has taken towards government-sponsored health insurance over the years. Samuel Gompers and, later, George Meany made much of keeping government at some distance, preferring to settle health and pension issues directly at the bargaining table with employers. Circumstances abetted this approach as developments—such as World War II, wage and price controls that left fringe benefits as the major negotiable item in collective bargaining, and post-New Deal antilabor efforts (notably the Taft-Hartley Act)—curbed labor's ability to organize. As a result of these combined pressures and opportunities, labor assumed the pragmatic position that pursuing collectively bargained health benefits was an effective means for membership recruitment and retention.
An analogous story unfolds in the political run-up to Medicare. Organized labor succeeded in the 1950s in garnering retiree health benefits for its members but at the cost of trade-offs in benefits for current workers. Eager to shift these retiree costs to the government, the Social Security Department of the AFL-CIO began pressing for public old-age health insurance. A key step in that effort was to set up the National Council of Senior Citizens (NCSC) to serve as a seniors' movement promoting Medicare legislation. Quadagno sees NCSC initiatives outflanking and "turning the tables" on the AMA as the 1960s efforts unfolded. Furthermore, the AMA had made a critical strategic error in supporting the Kerr-Mills legislation of 1960, which provided federal grant funds to the states to care for the poor old. However, rather than serving as a firewall against social insurance in health care as the AMA had hoped, Kerr-Mills helped legitimate the idea of a yet broader governmental role in the provision of health care insurance, including what was to become Medicare.
Quadagno emphasizes two underappreciated elements of the long and successful struggle for Medicare. The first centers on the central theme of failed national health insurance attempts, namely that Medicare took the winds out of national health insurance by both removing a "worthy and deserving" population from the pool of would-be beneficiaries and by removing a costly population from the pool of people that private health insurance might be expected to cover. Second, in an important bridging of civil rights and social policy, Quadagno reviews how Medicare served to integrate southern hospitals in a way no earlier welfare, health, or civil rights initiatives had. Whereas public health officials had long had difficulty in breaking down racially based health care barriers (they were, in fact, often "part of the communities"), Medicare was about money more than regulation. As Quadagno concludes, southern hospitals came around because they wanted to be on the receiving end of potentially very substantial federal funds.
Post-Medicare health policy was very much about cost containment. As a chapter subtitle suggests, no one—not the doctors, the hospitals, the insurers—wanted to rock the Medicare boat. Among other revealing material, Quadagno quotes a local medical society that, upon Medicare's passage, saw its role as not only "preparing doctors for July 1" (the date in 1966 when the program was launched), but also helping them to "adjust fees" that Medicare officials had been specifically banned from monitoring or curtailing.
Quadagno goes on to review what only readers of a certain age would recall, namely, that there was a time in the 1970s where it was thought that movement towards national health insurance had real prospects. Walter Reuther and Edward Kennedy were proponents, Richard Nixon had a plan, Jimmy Carter later sort of had a plan, and the health maintenance idea was put forward by Paul Ellwood and the Jackson Hole group as a means of dealing with endlessly escalating health care cost increases. But outside events (Watergate, the Iran hostage crisis) intervened, allies (Kennedy and Carter) had a parting of the ways, and, in the early 1980s, the imposition of diagnostic-related group reimbursement methodology split hospitals and physicians. Costs remained an overriding concern, but stakeholders—business, unions, and various providers—resisted all efforts to control them.
This state of events brought a new stakeholder—the "corporate purchaser"—into the picture. Quadagno insightfully dissects the politics of business and health, establishing in particular the distinction between corporate purchasers of health on the one hand and the larger business community on the other. Purchasing managers challenged both providers and state-level regulations that were leading to a broad expansion of coverages and enormous cost increases. In particular, the Washington Business Group on Health (WBGH), representing corporate purchasing interests, excluded provider interests from its membership. The WBGH lobbied for the government to pick up "catastrophic" coverages for the elderly, thereby shifting these costs from the private to public sector. These efforts helped lead to enactment of the Medicare Catastrophic Coverage Act of 1988; its later repeal—at the hands of the irate elderly—was a setback for business interests. It was also a setback for many low-income elders, who could have availed themselves of the benefits, and for many better-off elders who suffered when businesses began cutting back on retiree health care coverage in the 1990s.
The final stage of the saga finds emerging resistance by patients and providers to business attempts to rein in costs through heavy oversight and managed-care strictures. The 1990s were marked by a patchwork of legislative and regulatory health-related initiatives, resulting for the most part in compromise or defeat. Quadagno sees insurers as having regained the upper hand by defeating the Clinton administration health care initiative, watering down provisions of the Health Insurance Portability and Accountability Act of 1996 designed to broaden access to health insurance, and gaining tax benefits to encourage middle-class individuals to purchase private long-term insurance policies.
Quadagno's serial accounts of stakeholder mobilization (and demobilization) in the debates surrounding national health insureance are informative, detailed, and fascinating. She keeps both the casual and not-so-casual reader from getting lost in the internecine squabbling, never losing sight of her larger argument about these groups' critical roles. In particular, she emphasizes that the flagging primacy of physicians in resisting nation health insurance does not represent a repudiation of the larger stakeholder argument. The point is rather that new stakeholders with different sets of concerns emerged to promote their interests (profits, market share, autonomy, and control), each of which is inimical to the case for national health insurance. In condensed and short form, Quadagno's essential stakeholder argument is that the physicians who had prevailed in the fight against national health insurance during the last century's middle decades were ultimately supplanted by other private interests who succeeded in staving off greater public control and in shaping federal social and tax provisions to their advantage.
The Theoretical Place of Stakeholder Mobilization
As a case study in stakeholder politics, One Nation, Uninsured stands as a masterful volume. That stakeholders beyond the AMA stood ready to impede national health insurance developments has been a known but underemphasized factor in accounts of health policy developments in the United States. Quadagno demonstrates how other private interests and options emerged over time to have their day in the health policy sun. Indeed, Quadagno's very topic—why we don't have national health insurance—provides a platform for focusing on interest groups, who are as often trying to keep government from doing something as doing it on their behalf.
Quadagno's grand theory conclusions are both more encompassing and, partially as a result, less convincing. In the space of five pages in her first chapter and another five pages in her last, she asserts that four competing theories addressing social and health policy formation do not hold up as consistently as does stakeholder mobilization. Thus, she does not dispute that "anti-statist values" are always lurking around the edges of American domestic policy, but she questions whether such "values were a principal causal force" (p. 12) in blocking national health insurance development. In particular, Quadagno cannot reconcile passage of Medicare with the alleged salience of antistatist values in American policymaking.
Her brief case against "weak labor" as an impeding or absent force centers largely on labor's efforts in support of disability insurance in the 1950s and Medicare in the 1960s. In her estimation, these instances more than offset earlier episodes, including labor's animosity towards government intervention in both pensions and health insurance, its internecine differences as seen in the contrasting agendas of George Meany and Walther Reuther, and its essentially taking a pass during both the Carter and Clinton national health insurance episodes.
Quadagno acknowledges that "racial politics" was a major factor impeding social policy developments in the early 20th century, as southern politicians pressed for programs that were state and locally administered (Old-Age Assistance, Survivors Insurance). However, she sees southern congressional influence fading with the Democratic electoral landslide of 1964, passage of the Civil Rights Act in 1964, and the lure of Medicare's fiscal largesse, which succeeded in breaking down longstanding patterns of segregation in southern health care facilities.
Finally, Quadagno makes the case against the social sciences latest theory du jour on welfare state developments—"state structures and policy legacies"—as an explanation for national health insurance's failure. The structures or legacy argument applied to the United States hold that institutional barriers (federalism, divided government, checks and balances) and policy histories (political events at Time 2 are very much shaped by policy events at Time 1) generate political roadblocks and stasis that are extremely difficult to overcome. Thus, the theory suggests that, in the United States, essentially nothing is accomplished because our structures are hopelessly disparate and because Time 2 cannot follow Time 0. Contending that this approach seeks to explain so much that it explains very little, Quadagno determines in particular that it cannot accommodate enactment of either Disability Insurance or Medicare.
In contrast to these four inadequate approaches, Quadagno finds that stakeholder mobilization is present and accounted for throughout America's episodic national health insurance battles. In her words, "The evidence presented in the preceding chapters shows only one historical constant across every case, namely, 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" (p. 205). Quadagno suggests that physicians' political vulnerability, ultimately revealed through the disability insurance and Medicare episodes, led observers to take their eyes off of the place of stakeholders in general. In her estimation, the point more important than physicians' diminished role is that other private stakeholders—principally insurers—picked up the ball dropped by physicians and that they have dominated the game since.
The reader comes away from One Nation, Uninsured with a vivid and real sense of interest group power centered on the question of national health insurance. Many interests besides physicians had reason to resist the advancement of national health insurance. With her thorough review of extant literature, interviews with key actors, and revelations from archival material, Quadagno makes all of this abundantly clear.
Whether this is the entire picture is, of course, the larger question. If analysis focuses on proximate and organized political interests, it will likely conclude that such interests are critical to policy outcomes. The observer interested in exploring the place of antistatist values might well have taken a different tack, examining public opinion (ideological vs operational preferences of the public), engaging in content analysis of speeches, platforms, and media presentations, or exploring cultural values related to the role of government in general and in health care in particular. Analysts interested in institutional structures would (and have) emphasized the veto points that have helped scuttle national health insurance attempts, many of which are included in Quadagno's analysis: locally centered congressional nominations and elections (especially in the South), intracongressional committee fiefdoms, and dispersal of legislative authority across multiple domains. Somewhat ironically, such an emphasis is not inimical to Quadagno's own; there is a clear hand-in-glove relationship between the behaviors of private- and public-sector interests in politics and the loci in which they operate. Indeed, this is the crux of Theodore Lowi's (1969) well-known indictment of American politics as interest-group liberalism.
Exploring the essential contribution of this very fine volume leads to two concluding thoughts, one centered on the question of policy legacy and the other on whom we have selectively chosen as health policy beneficiaries in the United States.
The policy legacy question has been explored under various guises, usually under the colloquial rubric of "policy causing politics" (the reverse of the classic pluralist understanding). The validity of such approaches has received considerable attention, importantly for readers here, much of it focused on aging-related policy. Jack Walker's (1983) study of interest group formation and maintenance concluded that more than one half of 46 aging-related interests operating in Washington were formed after 1965, the watershed year when Medicare and the Older Americans Act were passed. More recently, Andrea Louise Campbell (2003) has persuasively argued that the post-1960s growth of Social Security has been a determining factor in creating the aged as a potent force in American domestic politics (again, not the other way around).
Yet, as Quadagno correctly observes, it has been harder to get American health policy in clear view through this lens than it has been the case with Social Security, the Older Americans Act, or the Age Discrimination in Employment Act. In short, what is the health policy legacy that one begins with? In this analysis (or any other focused on health), the Medicare story becomes critical. Apart from Hill-Burton, Kerr-Mills, and various public health initiatives, there was not much in place for Medicare proponents to build on.
But there was something. As readers of Theodore Marmor's (1970) classic account, The Politics of Medicare, are well aware, reformers dating to the New Deal period and veterans of the Truman years took stock of the political situation and turned their attention to the aged as a population that might overcome the antistatist attitudes that had long haunted attempts at national health insurance. These policy insiders—Isidore Falk, Oscar Ewing, and Wilbur Cohen—are the individuals who give agency to the "state structures" argument that Quadagno gives little weight to in her treatment. They follow in the model of the book widely held to have brought the state structure–policy legacy school to fruition, Hugh Heclo's (1974) Modern Social Politics in Britain and Sweden. Officials operating within public bureaucracies—even in the United States, the Medicare story might hold—engage in a cumulative process of "policy learning" that allows them to wield considerable influence in shaping agendas, imparting information, and guiding elected incumbents. Marmor's account combines the role of these individuals with an understanding of Medicare as a rare instance of truly redistributive legislation gaining a place on the American political agenda. That Medicare was enacted only for the old is certainly no more than half a loaf, but it is a half of a loaf that emphasizes how state actors overcame antistatist values by concentrating on a population which was, in Carole Haber's words, not among "the redeemable" (Haber, 1983).
Thus, a final thought centered on the aged. There is another relevant literature that Quadagno does not address, focused on "the politics of target populations." Most centrally associated with the writings of Anne Schneider and Helen Ingram (Ingram & Schneider, 1991; Schneider & Ingram, 1993), this construction stresses how differential levels of legitimacy and power among the targets of potential intervention help determine the outcome of policy processes. In the authors' four-fold construct along these dimensions, "the elderly" are posited as perhaps the prototypical favored constituency, being both highly legitimate and possessing considerable power. During Medicare's incubation period, it was unquestionably the seniors' political legitimacy that made them such a desirable target for health policy reformers. Seniors were not expected to work, were not able to save, and were presumed to be sick. They were the natural target.
Adding government insiders and target populations to the theoretical mix is important to get a fuller picture than Quadagno provides of what has and has not transpired around health policy. Yet, the policy legacy approach that can so neatly account for the extraordinary prominence that Social Security enjoys today cannot account as completely for health policy developments. Quadagno is very much on the mark in emphasizing the role of the AFL-CIO Social Security desk and the critical activities of labor-offshoot NCSC in Medicare's enactment. They were not alone in leading to Medicare's passage in 1965, but the newly organized aged had a role in Medicare that they did not have in Social Security or other policy arenas.
Conclusion
One Nation, Uninsured is, in its own terms, an extraordinarily persuasive volume. Equally important, it is clearly written and, in a manner unlike most academic books, tells a provocative story. It is a very difficult story to tell, and Quadagno is masterful at blending both themes and chronology. Moreover, she does so in a way that readers with varying levels of familiarity with health care issues will be able to follow. That the book is open to question from a macrotheoretical perspective is a second-order critique and, frankly, one that Quadagno invites by giving relatively short shrift to counterperspectives. Hopefully, there are some good journal articles forthcoming where Quadagno and her theoretical brethren can take each other on.
References
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