A Century of Failure: Class Barriers to Reform

Abstract To understand fully the persistent failure of the United States to enact national health insurance requires an appreciation not only of the role of government and the dynamics of politics but of underlying social realities. One consideration, which dates back to the Great Depression, is the absence of the middle class from a coalition in favor of such a policy. This absence reflects both the constricted vision of the middle class and the spirited campaigns of groups like Blue Cross to make certain that middle-class needs were met in order to reduce pressure for government intervention. Another critical social feature is the special entrepreneurial character of the American medical profession. Physicians saw themselves as small businessmen and, as such, shared and promoted a suspicion of governmental intervention. All the while, Americans justified the absence of a national program in terms of the ethos of voluntarism, which had a sufficient base in reality for the posture to be maintained without great embarrassment. In fact, the rhetoric that surrounded the enactment of Medicare reinforced these views, making it appear that, the elderly aside, all was well with the provision of medical services in the country. Even as national health insurance assumes a new prominence on the political agenda, it remains unclear whether these several considerations will allow for the enactment of sweeping changes.

There are some questions that historians return to so often that they become classics in the field, to be explored and reexplored, considered and reconsidered. No inquiry better qualifies for this designation than the question of why the United States has never enacted a national health insurance program. Why, with the exception of South Africa, does it remain the only industrialized country that has not implemented so fundamental a social welfare policy?

The roster of answers that have been provided is impressive in its insights. Some outstanding contributions to our understanding of the issues come from James Morone, Paul Starr, Theodore Marmor, and Theda Skocpol. Their explanations complement, rather than counter, each other. In like manner, the elements that this essay will explore are intended to supplement, not dislodge, their work. A failure in policy that is so basic is bound to be overdetermined, and therefore, efforts to fathom it will inevitably proceed in a variety of directions.

The Liberal State

Morone's frame for understanding American health policy in general and the failure of national health insurance in particular centers on the definitions of the proper role of the state, the acceptable limits for all governmental actions. His starting point is with the fact that the medical profession successfully "appropriated public authority to take charge of the health care field," taking for itself the task of denning the content, organization, and, perhaps most important, the financing of medical practice (Morone 1990: 253-84). This accomplishment points to more than the power of the American Medical Association's lobbying machine; AMA rhetoric, which has seemed to other observers to be bombastic, comical, or even hysterical, in Morone's terms was effective precisely because it drew on popularly shared assumptions about the proper relationship between governmental authority, professional capacity, and professional autonomy. By the terms of this consensus, the government's duty was to build up professional capacity without infringing on professional autonomy—and as long as the medical profession defined national health insurance as an infringement on its autonomy, such a policy would not be enacted. Government was permitted to build hospitals (witness the implementation of the Hill-Burton Act) and to endow the research establishment (witness the extraordinary growth of the National Institutes of Health), but it was not allowed, at least until very recently, to challenge or subvert professional autonomy.

Paul Starr also focuses on conceptions of state authority to explain health policy. Alert to the markedly different course of national health insurance in European countries, he posits that where a spirit of liberalism and a commitment to the inviolability of private property interests in relation to the state were strongest, movements for social insurance made the least headway. Thus, Bismarck's Germany could accomplish what Theodore Roosevelt's or Franklin Roosevelt's United States could not. Put another way, the fact that socialism never put down strong roots in this country, the absence here of a socialist tradition or threat, obviated the need for more conservative forces to buttress the social order through welfare measures.

Starr is more ready than Morone to credit the raw political power of the AMA, but he also reminds us that the AMA found allies among not only corporations but also labor unions. Union leaders preferred to obtain health care benefits for its members through contract negotiation, not through government largesse—even if that meant, or precisely because that meant, that nonunion members would go without benefits (Starr 1982: part 2).

Paralleling their studies are detailed accounts of the legislative histories of various health insurance proposals, the fate of Progressive, New Deal, and Fair Deal initiatives. The work of Theodore Marmor has clarified the political alliances that came together to enact Medicare and Medicaid (Marmor 1982). So too, the writings of Theda Skocpol place health care legislation more directly in the tradition of American welfare policies (Weir et al. 1988). In all, the existing...