Book Review

Chronic Politics: Health Care Security from FDR to George W. Bush

Poor People's Medicine: Medicaid and American Charity Care Since 1965

N Engl J Med 2006; 354:1859-1861April 27, 2006

Article

Chronic Politics: Health Care Security from FDR to George W. Bush
By Philip J. Funigiello. 395 pp. Lawrence, University Press of Kansas, 2005. $39.95. ISBN: 0-7006-1399-4

Poor People's Medicine: Medicaid and American Charity Care Since 1965
By Jonathan Engel. 318 pp. Durham, N.C., Duke University Press, 2006. $79.95 (cloth); $22.95 (paper). ISBN: 0-8223-3683-9 (cloth); 0-8223-3695-2 (paper).

More than 40 years have passed since Wilbur Mills, a fiscally conservative Arkansas Democrat and chairman of the House Ways and Means Committee, and Wilbur Cohen, health and Social Security adviser for Presidents John F. Kennedy and Lyndon B. Johnson, agreed in principle to the legislative structure that would create Medicare and Medicaid. On July 30, 1965, President Johnson signed the bill into law in Independence, Missouri, the birthplace of Harry S. Truman, thus honoring the first chief executive to advocate publicly for national health security. Unbeknownst to legislators, policy analysts, and advocates, the high tide in the pursuit of health security had just occurred. Since the turn of the 20th century, when the campaign of the American Association for Labor Legislation tried to persuade state legislators to pass health insurance laws, until today, health care security has remained one of the most pressing political and social issues in the United States.

The two books reviewed here, both thorough histories of health care reform, examine the country's ambivalence toward providing health care security as a right of citizenship. The United States has been unwilling to provide universal access to its private health system yet reluctant to abandon wholly the destitute, the permanently disabled, the elderly, and the young. Chronic Politics discusses our ambivalence as part of an extensive review of American efforts to legislate a national health security program, whereas Poor People's Medicine deals specifically with our ambivalence toward providing health care security for the poor, detailing the history of American charity care and the development of Medicaid.

Richly detailed, Chronic Politics captures the political stories behind legislative efforts to create national health care security. Philip Funigiello, professor emeritus of history at the College of William and Mary, examines the historical context of health care security and is clearly distressed at the American failure to create universal health coverage. Chronic Politics follows the actions and motives not only of presidents but also of many other important figures in the history of national health care security. We learn about many legislators who have made health care security legislation a priority, including Robert Wagner, Robert Kerr, Edward Kennedy (D-Mass.), and Wilbur Mills. We also meet a multitude of others who, outside the public view, invested their professional lives in pursuit of national health care security, from the social progressives who served on the Committee on the Costs of Medical Care during Franklin D. Roosevelt's administration to contemporaries who served on President Bill Clinton's Health Care Task Force.

From substantial archival research, Funigiello writes dramatic accounts of some of the most important moments in the history of national health care security: a heated exchange between Senator Robert Taft (R-Ohio) and Senator James Murray (D-Mont.) over whether President Truman's national health program bill was socialistic; the maneuvering and bargaining for votes of then Texas senator and majority leader Lyndon Johnson to shepherd passage of the 1956 disability amendment to the Social Security Act, in opposition to President Dwight D. Eisenhower; the negotiations between Wilbur Mills and Wilbur Cohen toward an agreement on Medicare legislation; the cataclysmic confrontations between President Clinton and House Speaker Newt Gingrich over both the Clinton health bill and the Republicans' proposed budget cuts to Medicare and Medicaid, which led to a shutdown of the federal government; and the unusual parliamentary tactics used by George W. Bush's administration to pass the 2003 Medicare Modernization Act.

Extensive and clearly written, Chronic Politics concludes with a thoughtful analysis of the repeated failures of the legislature to provide health care security. Funigiello identifies no shortage of obstacles. Both conservatives and liberals, Republicans and Democrats, have opposed such legislation. There has been intense resistance from interest groups representing the medical profession, private insurance companies, the pharmaceutical industry, and the federation of labor unions. The American ideological debate, pitting rugged individualism, private enterprise, and government distrust against cooperative pragmatism, social insurance, and community ethos, has never been settled. At the end of the last chapter of the book, Funigiello summarizes the challenges for future reformers, the most imposing of which is the need to rise above political differences. It is essential reading for legislators, policy analysts, and advocates interested in building momentum for national health security.

Poor People's Medicine, although as comprehensive as Chronic Politics, struggles to weave the historical narrative as tightly. Jonathan Engel, an associate professor and chair of Public and Healthcare Administration at Seton Hall University, reviews the history of charity medical care in the United States before providing detailed accounts of the implementation of Medicaid, the development of the program over time, and its effect on existing charity medical programs such as public hospitals, community clinics, and pro bono efforts by physicians. Less a political story than a scholarly assessment of efforts to provide charity care, Engel's work is made both more complex and more meaningful by the inclusion of an extensive history of the poor in the United States, including geographic and educational disparities and the “war on poverty.”

In the afterword, Engel describes themes emerging from our history of charity care: that efforts to provide charity care are long-standing, universal, and constant; that the modern provision of charity care belongs with government; and that, despite all its flaws, Medicaid has been highly successful. But he laments the presence of a two-tiered system in American health care: one for the poor, another for the rest.

Both Chronic Politics and Poor People's Medicine agree that the passage of Medicare and Medicaid was the most significant step forward in U.S. health care security for every citizen. Unfortunately, the journey toward health care security is not over, as large groups remain insecure, such as the 45 million uninsured; the working poor, who are underinsured and facing rising health insurance premiums and out-of-pocket costs; the poor, who are enrolled in Medicaid programs under growing pressure from state and federal legislators to cut benefits and eligibility; and all Americans, as the baby-boomer generation eases into the age when health care costs rise dramatically, threatening the solvency of Medicare and Medicaid and diminishing the capacity of the federal government to provide other social services. The social and political need to find realistic health security solutions remains very real.

Joseph S. Ross, M.D.
Robert Wood Johnson Clinical Scholars Program at Yale University, New Haven, CT 06520
joseph.s.ross@yale.edu