Book Review

One Nation, Uninsured: Why the U.S. Has No National Health Insurance

N Engl J Med 2005; 353:743-744August 18, 2005

Article

One Nation, Uninsured: Why the U.S. Has No National Health Insurance
By Jill Quadagno. 274 pp. New York, Oxford University Press, 2005. $28. ISBN: 0-19-516039-8

Over the past century, powerful organizations, industries, and groups have mobilized to oppose the enactment of national health insurance in the United States. Although the players on the opposition team have changed, and their ideologies have shifted, the result has been consistent. Interest groups that have stood to lose with the extension of coverage have ensured that universal coverage would not come to pass. So writes Jill Quadagno in One Nation, Uninsured.

Quadagno, a sociologist and an unabashed advocate of universal coverage, is clearly fascinated by this history. She tells it in a readable and engaging fashion. Starting with the failure of the campaign for compulsory health insurance in the Progressive Era and ending with the demise of President Bill Clinton's health plan, the book details the ways in which stakeholders — physicians, the business community, and insurers — have battled to maintain their positions. The victors in the battles have not only won as a result of their sheer financial power; they have also prevailed through coalition building and organizing at the grassroots level.

Much of the material in this book draws on previously published accounts. Some of the most interesting portions come from Quadagno's own archival searches and her interviews with people who lived the history that she describes. This is a tale that spans nearly a century, and in a short book, some richness is inevitably lost. The material covering the early years tends to be more nuanced than that of more recent events, such as the failure of the Clinton health plan.

One difficulty with the book is that its audience is not clearly defined. On the one hand, Quadagno addresses sophisticated debates in political causality; indeed, in invoking stakeholder politics, one of her objectives is to put forth a kind of “unified field theory” to explain the failure of universal coverage. On the other hand, she takes the time to define rudimentary terms such as “filibustering” and to summarize the very basics of programs such as Temporary Assistance to Needy Families and welfare reform.

For physicians who share Quadagno's taste for universal coverage, this look backward at a series of missed opportunities is rather bleak. This is not a history from which such readers can draw much professional pride. Nor does Quadagno's analysis offer much hope that physicians will be central players in health care reform in the near future, given their current organizational fragmentation. In the final pages of the book, the author looks forward, presenting a brief sketch of how a coalition of diverse groups (including employers, the elderly, organized labor, and the uninsured) might work together to achieve what has repeatedly failed to come to fruition over the past century. Although some readers may consider this an unlikely picture of the near future, Quadagno's sustained focus on interest-group politics seems right on target.

Jan Blustein, M.D., Ph.D.
Wagner Graduate School at New York University, New York, NY 10012