| Book Review | Health and History, 7.2

Book Review

Health Security for All: Dreams of Universal Health Care in America. By Alan Derickson (Johns Hopkins University Press, Baltimore and London, 2005, hb, ISBN 0-8018-8081-5) 256pp.

Alan Derickson, professor of American history at Pennsylvania State University, has written a slim book that is part intellectual history and part policy history. He tells the story of the ideal of universal access to health care in the United States (not 'America,' despite his wording), and of various plans over the years to further this aim. Derickson supports the 'noble goal' (p. xii) of health security for all and ends by suggesting how it might be achieved.

Derickson shows that Progressive reformers at the turn of the twentieth century exposed the problem of unexpected and costly medical care. Their vision was limited to helping only workers and their families through social insurance, however, and they had no success in achieving even that goal. Insurance companies and the president of the American Federation of Labor, Samuel Gompers, objected to government action. Efforts to foster state medicine in the 1920s were opposed by the American Medical Association and also failed. President Franklin Roosevelt wanted to add health insurance to his social security act, but he gave up the idea rather than place the entire bill at risk of defeat. Still, the law's contributory taxes created a sense of entitlement and encouraged talk of a right to medical care. As a result of Roosevelt's success, reform efforts after the New Deal focused on workers and payroll financing, not citizens and general revenues. Another legacy of the 1930s was the change from crusades at the state level to calls for action in Washington. World War II encouraged the growth of job-based benefits in order to lure workers, however, and Southern racists and the Cold War held back socialized medicine. The idea of national health insurance rose again in the liberal 1960s, which saw the enactment of Medicare and Medicaid. However, complete coverage did not develop. The Clintons' convoluted reform effort, initially devoted to universality, failed to gain enough political support to pass. Despite a century of debate, 44 million citizens had no health insurance in 2002.

Health Security for All is a useful primer. It describes thinking about health security and outlines the major campaigns for reform, explaining the extent to which they could have given security to the U.S. population. The sixty pages of notes refer to a wide range of primary and secondary sources.

The problem is that the subject is too big to deal with adequately in just 165 pages of text. Vital chunks of the story are missing. There is no discussion of the extensive arrangements for the military or justifications for them. Medicare—the major U.S. programme–suddenly appears and is outlined in about 100 words, with almost no discussion of its origins or details. Derickson underplays the political dimension throughout the book, so that the fortunes of reform efforts seem to depend on debating points rather than the realities of campaign contributions and judicial matters. Similarly, his concluding call for a coalition to achieve health security for all—leaving aside the question of whether or not a work of scholarship is compromised by such advocacy—ignores the distribution of political power within the U.S. system of government. 'The defeatism that surrounds the issue' (p. 165) is actually realism.

The book is disappointing on some points of scholarship. First, Derickson's opening sentence ('It is well known that the United States entered the twenty-first century as the only affluent nation in the world that does not guarantee its citizens access to basic health care.') is doubtful. All nations ration health care in some way, and all developed nations, including the United States, have forms of governmental provision. It is very hard to make international comparisons, and Derickson provides no evidence for his assumption. Second, his prejudices and economic naivety are clear in several places, such as when he criticizes employers of the 1960s for their 'inability to grasp that they could afford to offer employee health benefits' (p. 128). Third, several times, Derickson claims that historians have overlooked some point or other; he is mistaken each time. For example, the incompleteness of coverage under U.S. programmes has been a common theme in writing on health policy, but Derickson insists his attention to universality is new. The difference in focus is slight.

Perhaps Derickson would have been better to write purely intellectual history, where he makes a useful contribution. His book contains the history of an important idea. When he dips into political and practical matters, however, he leaves this reader unsatisfied.

Raymond Richards

University of Waikato, New Zealand

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