Why the United States Lacks a National Health Insurance Program

Health Care Policy in the United States

Health care policymaking is surely one of the most remarkable issues of the day. There are few other policy debates of comparable gravity that connect fundamental issues of fairness, of life chances, and of enormous financial consequences. Health care expenditure is about fifteen per cent of gross national product. The absence of a national health insurance system is often used as a prime illustration of America's exceptionalism, singular in its refusal to adopt a system of universal health care access similar to what is found in other advanced industrial nations.

The current debate over national health care insurance is perhaps more intense because there is a widely held expectation that large scale reform may now actually come to pass. But the debate is not new. Over the course of this century, there have been recurring debates over whether or not to adopt a system of national health care. For policy analysts, the task of explication is surely daunting, for the landscape of health care politics is vast and the terrain difficult.

The challenge for analysts of American exceptionalism in health care is found, first, in sorting out an appropriate strategy of inquiry about why America has come late (if arrived at all) to establishing a national health care system. The challenge also lies in determining how much of the terrain can be explored persuasively by relying exclusively on a specific tradition of policy analysis, such as interest group theory. In one of the books reviewed, Laham's, the problem is seen through the lens of interest group politics. In the other, Mueller's, the focus is institutional: how the distinctive nature of American policymaking defies the development of comprehensive solutions to public policy problems.

Critics of policy studies argue that the field is characterized by ambiguity. This is certainly not the case with Laham's study. It is both focused and prescriptive. The book provides an answer to the question posed by its title: Why the United States lacks national health insurance. The answer is found in the long standing, effective resistance of the health care industry lobby, most specifically the American Medical Association (AMA). Laham believes that the formidable lobbying of the AMA and its allies has repeatedly defeated, over the course of this century, American presidents and congressional coalitions committed to realizing hospital reform and/or national health insurance. Laham concludes that, although the health care industry has been effective, it has also been quite harmful for the body politic. Our present system of providing health care has become so expensive that soon the substantial minority without or with little health insurance will become the majority, resulting in the imposition of national health care in the next few years.

Laham gives a spirited critique of the health care industry in frustrating decades of efforts to realize health care reform. He concentrates almost exclusively on the role of the health care lobby to the detriment of other factors such as federalism or the remarkable number of actors active in health care issues. His often passionate account could be strengthened by employing an explicit analytical framework. The rich range of group theories and the recent work of institutionalists could greatly strengthen Laham's explanation of why it has been harder in the United States to establish national health care than in other countries, and why current reform efforts are made all the more difficult by the growing range of health care players.

Mueller's study provides a quite persuasive, well argued account of why health care policy in the United States is often innovative in specific areas but has failed to achieve comprehensive national policies. At the macro or national level, Mueller argues, relatively little in the way of comprehensive change has taken place. When changes are introduced at the national level, moreover, they often turn out to be ineffectual.

Mueller proposes three recurring themes in American health policy: quality, access and cost containment. In a particular era, one of these themes dominates policy discussions, as is the case with cost containment in contemporary health policy debates. But even when a theme is dominant in public debate, it is inevitably weakened in policy application. Mueller argues that American public policy is made incrementally and segmentally. The culture of incrementalism seriously constrains the effectiveness of public policy. Cost containment, for example, may be achieved by regulating inpatient hospital costs, but rising costs over time are simply shifted from regulated inpatient care to the unregulated outpatient care sector. It is only when conditions become quite adverse that incrementalism can be overcome and large scale reform achieved.

Mueller offers a comparative perspective presumably to assess the extent to which incrementalism is a particular American phenomenon. But his comparative analysis is largely limited to a brief account of Canadian efforts. The treatment is too brief to develop persuasive thematic comparisons with policymaking in other nations.

Mueller's book is a well researched and thoughtful integration of theory and research findings. Mueller is persuasive in his use of theoretical constructs and in his survey of research findings in developing an explanation of why the American system is both innovative and ineffectual at the same time. This study is an important and timely contribution to the national health care debate.

There is an irony to the present debate over health care insurance that both studies help us to appreciate. In most countries, national health insurance was justified politically as a benefit for a deserving population. Today in the United States, we have health care insurance proposed as a benefit that also contains costs. This is a combination that makes the current debate a complex and fragile exercise in public policymaking.

John Francis
University of Utah

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