Book Review

Health Security for All: Dreams of Universal Health Care in America

Healthy, Wealthy, and Fair: Health Care and the Good Society

N Engl J Med 2005; 353:1866-1867October 27, 2005

Article

Health Security for All: Dreams of Universal Health Care in America
By Alan Derickson. 240 pp. Baltimore, Johns Hopkins University Press, 2005. $30. ISBN: 0-8018-8081-5

Healthy, Wealthy, and Fair: Health Care and the Good Society
Edited by James A. Morone and Lawrence R. Jacobs. 382 pp. New York, Oxford University Press, 2005. $29.95. ISBN: 0-19-517066-0

When we see a family grieving over the illness of a child and know that nothing can be done, we are disheartened and think, “Life can be unfair.” We can be heartened, however, whenever recognized institutions take up the cause of unfair circumstances that can be changed. The Institute of Medicine has advised the nation about the harmful effects of being uninsured. At a time when employer-based health care benefits, Medicare, and Medicaid cover a large majority of the U.S. population, it is estimated that 45 million persons are currently uninsured and a total of 80 million will be uninsured sometime within the next two years — and these numbers are growing. Concern has been ignited about the consequences to the individual and to society of this lack of coverage: although they are sicker and have a greater risk of death, uninsured persons use about half the medical care that insured persons use, and costs for the uninsured are borne by government, business, and the health care sector.

The Institute of Medicine identified universal health care coverage as the first principle for ensuring the health of all Americans and called on the federal government to reach this goal by 2010. Two recent books touch the heart and mind as we learn of the history and realities confronting this task. These books will surely resonate in the thoughts of policymakers, public health and public policy scholars, and anyone interested in a fairer and healthier society.

Health Security for All explores the development of social thought and of efforts during the 20th century to make health care accessible to all Americans. Alan Derickson, a historian, begins by tracing the ideal of universal access to the beginning of that century, when Progressive Era reformers articulated the beliefs that ill health was a cause of poverty, that health care was an essential human need, and that human needs in and of themselves confer human rights. Early in the book, Derickson makes the point that although the term “universal” is currently associated with national health insurance, strategies for coverage have historically ranged across the ideological spectrum — from totally public systems to public–private systems to totally private systems. His hope is that those who pursue the goal of universal access will profit from an understanding of efforts and errors of the past.

As an example of attempts at health care reform, the legendary Committee on the Costs of Medical Care — made up of distinguished medical and academic leaders — convened in 1927 with a professed belief in universal access. Five years later, the committee splintered without having agreed on a course of action. This and other failed efforts demonstrate that mere agreement on the principle of universal access does not translate into action. A central thesis of the book is that history is replete with efforts by uncompromising policy intellectuals, undertaken without the active support of those in need of health care. Clearly, many other events have contributed to lost opportunities, including the steady growth, over several decades, of voluntary employer-based insurance, which lured the United States into believing that the numbers of insured persons would only increase.

Derickson concludes with this intriguing thought: “The failure of several reform campaigns relying heavily on elite expertise suggests the imperative need to build a mass movement among the uninsured to reframe the policy debate and the political contest.” He asks: “If breathless coal miners, AIDS victims, and profoundly disabled Americans can build effective mass movements, why can't the uninsured?”

Many other social and economic circumstances affect the health of the population. At present, the United States is faced with the conundrum that it spends more on health care but has poorer health outcomes than other wealthy nations do. The Robert Wood Johnson Foundation called on recognized scholars with expertise in health policy to explain this state of affairs and to imagine a fairer and healthier society.

Healthy, Wealthy, and Fair is a compilation of essays by 15 such scholars, who reflect on current issues from the perspectives of diverse disciplines, including public health, social epidemiology, and political science. In the first chapter, Ichiro Kawachi sets the theme of the book by comparing the 13 most economically advanced nations. The United States ranks low or lowest in terms of measures such as life expectancy and years of potential life lost, and within the United States there are wide disparities in health according to race and socioeconomic status. Kawachi attributes the country's poor health standing to three interrelated factors — poverty, economic inequality, and an inadequate health care system — and observes that if the United States ranked as low in the Olympics as it does in national health, Congress would immediately pour money into athletic programs.

The book provides several examples of the lessons for health care reform. Benjamin Page argues that political inequality enables affluent interest groups to perpetuate the myth that Americans are persistently against government and against tax-based financing. Lawrence Brown compares the different risks involved in enacting a health care strategy encompassing comprehensive reform and one based on incrementalism. Marie Gottschalk writes that, notwithstanding the decline in membership, organized labor remains important to the health care debate — but she notes that labor's attachment to employer-based insurance impedes severing the tie between health care and employment status. Mark Peterson sheds light on past efforts that contributed to making Congress a “graveyard” for health care reform (“not a single health care reform initiative has ever come to a vote on the floor of either chamber” of Congress); Congress, however, continually changes and evolves and, in that way, presents new possibilities for health care reform.

The most disquieting lessons concern the “dangers of the market panacea.” To control health care costs and provide patients with more choices, many influential health policymakers have embraced competition and other market principles. Mark Schlesinger makes the case that “market thinking” begins to reshape medical care into a market-like commodity and that policymakers and the public are divided in their support for applying market principles to health care. In a related essay, Deborah Stone writes that medical care, which should be available according to medical need, will also flow through economic channels of supply and demand. Both authors argue that market-oriented health care is likely to exacerbate racial and social inequalities in health.

James Morone and Lawrence Jacobs, the editors of this book, view the poor health standing of the United States as the price we pay for policies that sustain social and economic inequalities. They believe a resurgence of our egalitarian traditions is needed to reduce inequalities in health, and they end with the hopeful note that if other economically advanced nations successfully protect the health of their people, the United States can, too.

Marian E. Gornick
Centers for Medicare and Medicaid Services (Retired), Baltimore, MD 21244
mgornick@aol.com