23 of 25 people found the following review helpful:
4.0 out of 5 stars
Your Money and Your Life, June 3, 2003
This review is from: Dead on Arrival: The Politics of Health Care in Twentieth-Century America (Politics and Society in Twentieth Century America) (Hardcover)
American politicians like to pride themselves on their pragmatism: Colin Gordon provides the valuable tale of how "pragmatism" got the United States Health Care system into an ungodly mess. By 1990 the United States spent 13% of its GNP on health care, while no other OECD country spent more than 9%. And yet at any given time at least 15% of Americans lack proper health insurance, while much of the insured's coverage is spotty and sacrificed to insurer profits. The generous system of remuneration practically breeds health care inflation. As one public relations consultant warned medical conservatives in 1961, the United States was the only major country not to have some form of national health insurance. He pointed out that if such a system was the high cost, low quality mess the AMA claimed it was, why hadn't conservatives in the 59 countries that had adapted successfully convinced people to change their minds and adapt the American system? A good question, but the AMA, the insurers, the hospitals and major employers have been alarmingly successful at keeping common sense at bay. Why is this the case?
Colin Gordon notes contrasting explanations such as American ideological opposition to government assistance, the institutional weaknesses of governmental welfare structures, and the power of anti-welfare capital. He points out the weakness of the first argument: national health insurance has always been popular in opinion polls. And the American government has improved its bureaucratic capacity over the years. The real problem is that, thanks to the nature of American politics and past mistakes, the forces supporting national health insurance have been weakened and fragmented and have never been able to match the influence of the powerful health care lobbies. Gordon's book is very well researched. It relies on 74 sets of private papers and oral histories, including in-depth use of the Johnson and Nixon presidential libraries. He starts with an overview of the various attempts to achieve health insurance during the Progressive Era and the New Deal, and the thwarted attempts to achieve something under Truman, Johnson, Nixon and Clinton. He then discusses the way labor unions tried to create a private welfare state, and then discusses how reformers got themselves into endless muddles by trying to use the metaphors of contractual insurance. He then discusses the ideological themes of national health care insurance's opponents, then the way racism has hampered the health care debate. Finally he looks at the way the opponents of health care insurance successfully mobilized, while the health care reformers were always checkmated. The result is a fascinating portrait of selfishness. We see the AMA and its Republican allies successfully redbait national health care insurance as Communist, Nazi or even tied to the Kaiser. (One propagandist went so far as to argue the Holocaust wouldn't have happened if Bismarck hadn't socialized medicine.) We see British doctors, Canadian bankers and The Economist bemused at the AMA's distortion of British and Canadian medicine. (The AMA responded by preventing local medical societies from investigating British medicine for themselves). We see Republicans complaining that if the government could provide free health care, why not free toupees? Racism, sexism, misogyny all play their parts in the private health care's arguments. We see how they argue that they shouldn't have to pay the cost of keeping African-Americans well. Their illness and poverty are, of course, their own fault, not that of the doctors who refuse to treat them or the society that seeks to degrade them. We learn how health care, like welfare, is divided into "deserving" and "undeserving" citizens and services. We also learn how Johnson's officials faced the challenge of segregated and grossly unequal hospitals and promptly ran away.
More important, we also learn about the failed logic of reform. While there is an understandable constituency of doctors to make as much money as possible privately, there are understandably fewer doctors willing to do what is best for their patients. In other countries political parties and trade unions would take up the slack, but not in the United States. As Gordon points out political parties are notoriously difficult to influence in the public interest. Both parties prefer limited political mobilization, low voter turnout and interest-based organization, rather than make the sustained mobilization national health insurance would require. For the Democrats, reform was hampered until the sixties by the strength of their authoritarian and reactionary Southern base. After the sixties the party moved to the right and relentlessly tried to flatter business to support them. Gordon is particularly good about the failure of the Clinton Health Plan. For once, doctors, hospitals, insurers and employers had different interests. But instead of choosing one group, Clinton and his colleagues tried to soothe them all. They threw away their best asset, popular support for national health insurance and appeals on grounds of universality and equity, for a technocratic solution that could mobilize no-one. But it was not possible to satisfy everyone since their interests conflicted, and the attempt to do so either annoyed some groups or weakened their lukewarm support. Gordon goes on to discuss how unions, group health advocates, and people concerned about black health care could have hypothetically pushed for national health insurance. But unions were too weak to influence a Democratic party hampered by Jim Crow. In supporting their own private welfare state, they undercut support for universal health care, made further reform more difficult and ultimately put their trust in a system that would be ravaged by deindustrialization and deunionization. The same problem occurred with group health, maternal health and black health advocates, as they supported short-term measures that made fundamental reform impossible. If the story of liberal reform is one of compromise, Gordon tells the tale of how reformers compromised themselves to death.
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