Academic Gerard Boychuk illuminates why the United States has followed such a different course of public policy on health care from Canada's: (
PDF)
The politics of race were a central fixture of the period in which American public health insurance policy initially emerged and help to explain both the lack of national public health insurance as well as the specific structure and characteristics of the programs that did develop...
The politics of race had not been a significant barrier to the inception of public health insurance prior to the end of World War II. Had a national program of health insurance been implemented before this point, it almost certainly would have adopted the racialized cast of the existing social programs comprising the American welfare state. To this point, southern Democrats in Congress maintained an effective veto over new programs and, as a result, retained powerful mechanisms to ensure that new programs would not challenge the existing racial status quo...
They could do this by directly excluding African Americans in the South (e.g., by making farm workers and domestic servants, a big part of the African-American population of the South, ineligible) or by leaving administration to states or localities, and letting them either deny benefits or pay lower benefits than to whites.
Health insurance should have been included in the New Deal, because left as it was until later, it became entangled in the post-war politics of civil rights.
In the immediate postwar period, the ability of the South to enforce an effective policy of segregation on the federal government was challenged as was the racial status quo in the South. The federal government abandoned its official policy of racial segregation beginning with the integration of the American Armed forces by executive order in July 1948. As the federal government became more clearly committed to desegregation after World War II, federal intervention in virtually any policy area could be construed as a potential future challenge to the racial status quo. Due to the highly segregated nature of health services provision in the United States, especially--but not exclusively--in the South, it was virtually inevitable that the politics of public health insurance would become inextricably entwined with the emerging political battles over civil rights. This certainly proved to be the case with President Harry S. Truman's attempts--the first by an American president--to enact national public health insurance in the period from 1948-50. Truman's linking of civil rights and health insurance in his 1947 State of the Nation address and his appointment of a high profile integrationist to lead his administration's health care reform exacerbated southern fears that a national program would challenge the racial segregation of health services in the South...
By the 1960s, circumstances relating to both civil rights and public health insurance had changed dramatically. Segregation in health care services had come on the defensive even in the absence of federal programs. Segregation in education had been found unconstitutional in 1954, and there was every reason to believe that similar court challenges would emerge in the area of health services. The passage of the Civil Rights Act, 1964 made such challenges even more likely. Moreover, the provision of the existing federal program for cost-sharing hospital construction enacted in 1946, which explicitly allowed segregation, was struck down in 1962 by the Supreme Court...
Involvement by the federal government threatened the end of being able to keep health services segregated. Only when court challenges began to force the end of legal segregation anyway did the prospect of federal funds make compromise possible.
For their part, southern lawmakers needed to be able to support health legislation without appearing to be promoting hospital integration and the financial incentives would have to be sufficient to help them sell the program politically. Thus, the administration adopted a deliberate strategy of uncoupling the issue of health insurance from the issue of civil rights, although it was proceeding on both fronts simultaneously--a significant shift in strategy from the late 1940s. The administration strove to ensure that the civil rights implications of the Medicare program were never discussed on the congressional floor, and African-American organizations were conspicuously absent from discussions surrounding Medicare, including the proceedings of congressional committees. Medicaid, a program of federal cost-sharing for medical services provided to needy persons, was added at the last minute and would sweeten the deal for southern representatives, further tilting the balance between the risk of federal intrusion and the flow of federal funds toward the latter. (Not surprisingly, the matching formula favoured poorer states, including virtually all southern states.) At the same time, Medicaid recreated the AFDC compromise in the New Deal and left eligibility, benefit levels, and administration to the states. In order to ensure the limited enforcement of the Civil Rights Act, nursing home care would be included in the Medicaid program for the needy rather than the Medicare program for the aged.
In anticipation of resistance by southern hospitals to the enforcement of civil rights compliance--a key concern of Medicare policy-makers at the program's inception and an issue with which President Johnson himself would become personally concerned--the resulting package included financial terms that were extremely favourable to hospitals and the medical profession in order to prevent broader physician and hospital opposition. These compromises greatly contributed to the overall costs of the program as well as its lack of fiscal controls which, in turn, significantly constrained future reforms. Together these factors dashed the hopes of liberal reformers and assuaged the concern of conservative opponents that Medicare would act as a stepping stone to universal public health insurance. (For more than 20 years, the central challenge for federal policy-makers would be the struggle to bring costs under control.)...
And the next serious push for national health care, in the 1990s, was similarly shaped by race. Though Clinton's health care reform plan was sold as primarily benefiting the middle-class, since the very poor, who did have a racialized image, were already covered by other programs, the politics of race was still successfully used to scuttle reform.
At the same time, however, dynamics relating to race contributed to an overall context that was inhospitable to health insurance reform. First, the heightened racial charging of the American political system in the early 1990s – a context to which the Clinton administration's proposals for welfare reform and crime control contributed – helped undermine general public support for both expansion of federal programs and increases in taxes necessary to fund them. This greatly constrained the Clinton reformers' latitude in designing their package of health reforms. On the tax side, the lack of public support for higher taxes, which was also strongly conditioned by concerns about spending on minorities, created a context in which the Clinton administration felt bound to adopt an approach which was revenue-neutral. In turn, the failure of the plan to specify new revenue sources became an important element in the declining popularity of the Clinton proposals as important constituencies such as seniors became convinced that the expansion of coverage to the uninsured would be financed through cuts to their own coverage. Secondly, the heightened racial charging of the American political system in the early 1990s also contributed to lowering the public salience of health care relative to other issues which more directly played on racial dynamics such as welfare reform and crime control where reforms would ultimately be successful.
At least welfare reform and crime control are not current issues. Anxiety about immigration is more than taking their place though. The rest of the dynamic is eerily similar.
And now here we are with an African-American president and on the brink of real health care reform. The ethnographic shifts in the electorate that allowed Obama to win the presidency may be enough to shift the historic tide on the issue, at least if the
undemocratic Senate doesn't cause the effort to fail.
I think the history of the struggle for national health care in the US - the only developed country without it - is still infused with tensions over race. It's just become more difficult for opponents to come right out and state that they don't want to share the benefits of society with others not like themselves. Thus the undercurrent of
racism and the retreat into a blizzard of lies and arguments against reform that make no apparent sense. It's because they just can't own up in most cases to what their opposition is really about.
the
book
