Jill Quadagno, One Nation Uninsured: Why the U.S. Has no National Health Insurance.

Jill Quadagno, One Nation Uninsured: Why the U.S. Has no National Health Insurance. New York: Oxford University Press, 2005. $28.00 hardcover.

Perhaps the clearest mark of American Exceptionalism is our failure to have enacted a program of universal health care; we remain the only advanced industrial nation not to have done so. Why no national health in the United States? is a question worthy of the same consideration as Werner Sombart's famous and much pondered query, Why no socialism? The curiousness is amplified when we note that throughout the twentieth century, the American public has consistently voiced support for some form of universal, national health care.

While Jill Quadagno's One Nation Uninsured offers a nuanced kind of explanation, it is ultimately a story of the power of interest group influence in an pluralist political system, albeit one in which business and professional organizations do occupy a privileged place: "stakeholder mobilization [has been] the primary obstacle to national health insurance" she argues (p. 11). What distinguishes this from accounts that merely lay the blame at the feet of the American Medical Association, however, is that Quadagno takes pains to demonstrate that the AMA alone had little power--only when physicians were able to act as part of a larger coalition of interests were they able to effectively shape or stop reform. (And if they could effectively portray reform efforts as a socialistic plot, all the better). So instead of a single protagonist, there are many here, a shifting cast of characters that includes trade unions (which throughout the early century especially sought private benefits for their employees and distanced themselves from or opposed a national program), business interests (sometimes united in opposition, at other times divided into larger corporations seeking to shed medical costs and small businesses fearful of new mandates), insurers, hospitals, and an array of politicians dependent upon one group or another for their electoral successes.

How then can we explain the enactment of national health care for the old and the very poor? Medicare and Medicaid finally succeeded, Quadagno argues, because, with over two-thirds of the public already insured privately, the consequences of public insurance for the old and poor were seen as minimal, and thus mobilized opposition was correspondingly weak. But Quadagno also notes the weakened public image of the AMA, in part the result of some episodes of overreach; the enormous electoral victory of Johnson and the Congressional Democrats in 1964; the mobilization of the AFL-CIO in favor of Medicare; and Ways and Means Committee Chairman Wilbur Mills' strategic commitment to getting a plan enacted.

The problem is that Quadagno's account does not help separate out the relative import of these and other factors--the AMA may have not fought as vigorously, perhaps, and lost the American Hospital Association, the insurance industry, and Blue Cross as allies this time around, but the political landscape might have made their task unusually difficult even absent these circumstances. It is in this way that One Nation, Uninsured may be better as history than as social science, for there is something of a forest for the trees problem here: much of the book is taken up with a legislative history (and it is good history and close analysis), but there is too little by way of theory or larger argument to help fully make sense of these developments or to put them in a context. It can thus seem as if healthcare policy in America is just the product of one damned thing after another.

That said, this is a work with much to recommend it. Much of Quadagno's account is a useful contribution to the growing policy history literature. Crucial to the tale told here, for example, is FDR's decision to strip universal health care from the SSA out of fear that it would weaken chances of enacting the bill. Once private employer- and union-based programs stepped into the breach, the opportunity for and demand for public solutions was lessened, further privileging privately-run (if often publicly-subsidized) solutions. And the manner in which Quadagno demonstrates the immediate medical cost inflation that Medicare caused and how that, in turn, weakened support for universal coverage in favor of cost-containment, offers a fine lesson in unanticipated consequences. Further, Chapter Three, "Provider Sovereignty and Civil Rights," is especially worthy of attention: once again, as in her book The Color of Welfare, Quadagno may be at her best when tracking the effects of race, here powerfully demonstrating how Title VI of the Civil Rights Act of 1964, when leveraged with the economic incentives and enforcement power of Medicare, helped finally to desegregate hospitals in the south. And finally, while there is little attention here to Clinton's failure to enact universal health care, in the context of Quadagno's rich history, it is not a unique event but just another step in a long line of failed twentieth century attempts at reform.

Stephen Pimpare

Yeshiva University