Rick Mayes on the elusive quest for national health insurance

Book Review by Don McCanne
The New England Journal of Medicine
July 7, 2005

Universal Coverage: The Elusive Quest for National Health Insurance

(Conversations in Medicine and Society.) By Rick Mayes. 207 pp. Ann Arbor, University of Michigan Press, 2004. $26.95. ISBN 0-472-11457-3.

Observers of the U.S. health care scene cannot help but be perplexed by the enigma of a system of funding health care that leaves so many patients financially vulnerable, in spite of per capita spending on medical care that is almost twice that of the average industrialized nation. We tend to look for relatively simplistic explanations of this phenomenon, but most theories are too narrowly focused to provide adequate enlightenment. In contrast, in this book, Rick Mayes provides a political history of the reform movement that demonstrates why it seems almost improbable that national health insurance ever could have reached the threshold of political feasibility.

Mayes begins with President Franklin Roosevelt's decision to abandon his attempt to include national health insurance in his Social Security legislation. Roosevelt feared that the opposition of the politically influential American Medical Association would doom his entire program, a risk that he dared not take. Mayes then describes several other critical junctures at which comprehensive reform again seemed feasible but failed each time, primarily because of a lack of the requisite political alignment of influential interests. The one notable exception was the success during the Johnson administration in enacting the Medicare and Medicaid programs. Mayes ends with a description of the politically inept effort of the Clintons, which never could have produced a consensus.

Perhaps the most important contribution to understanding why the quest for universal coverage remains elusive is Mayes's description of the various incremental measures that were effective in increasing coverage but, ironically, solidly institutionalized the reforms and thus made it more and more difficult to enact a universal system. Even Social Security, as one of the most popular government programs ever, was a factor, since Medicare was a logical expansion of the provision of security in retirement. Labor's eventual support of employer-sponsored coverage, with the acquiescence of business interests, firmly secured the position of the insurance industry as a major player in health care funding. Medicaid nominally fulfills the commitment to provide coverage for patients in poverty, and many believe that tweaking this program would provide the final major increment of bringing in low-income people who currently do not qualify for Medicaid.

Although Mayes does fill in the blanks in confronting the complexities of health care reform, nevertheless it is clear why many observers believe that refinement of our current institutions would be adequate and that a comprehensive national health insurance program is not necessary.

Such complacency ignores the fact that many of the tens of millions of people without coverage do suffer adverse health outcomes and even death.

Also disconcerting is the fact that the newer, ubiquitous, innovative insurance products are no longer adequate to ensure either financial security or health security. But Mayes does give us hope. Although he acknowledges that critical junctures are rare, he notes that they do occur, especially in response to unmet social needs. Perhaps the deterioration in insurance coverage that has taken place may have brought us much closer to our next critical juncture than most of us realize.

Don R. McCanne, M.D.
Physicians for a National Health Program Chicago, IL 60602

Copyrighted © 2005 Massachusetts Medical Society