Health Care for Some: Rights and Rationing in the United States Since 1930

When I was in the UK recently, everyone from taxi drivers to academics asked me: "Why don't Americans want healthcare?" Americans do (at least for themselves), but politicians raise the spectre of UK-style "rationing" when we demand universal coverage. The US does ration care, Beatrix Hoffman argues, but rarely acknowledges it. Hoffman's goal is to encourage an honest debate about healthcare reform by identifying the varied forms of healthcare rationing. Health Care for Some examines access to and denial of care in US medicine since 1930. It is a well-researched, readable primer on the development of the complex, fragmented US medical system. The glossary will help US and non-US readers alike navigate the crazy-quilt configuration of the country's medical marketplace.

Americans have never had healthcare as a right of citizenship. Rather, medical care is a commodity accessible chiefly to those with the ability to pay. As medicine's efficacy increased in the 20th century, so did its cost - and the ethical questions about denying anyone its benefits. Hoffman paints a striking picture of the human face of need, obstacles to medical care and government programmes that have provided medical assistance for some groups of people. She skilfully interweaves grass-roots voices with policy explanations.

During the Great Depression, hospitals and doctors urged federal and state governments to subsidise private medical care, not on the grounds that all people had a right to healthcare, but that providers had a right to compensation. Hoffman identifies government protection of the rights of hospitals, providers and insurers over those of citizen-patients as a central tension in US healthcare. Public funds that were intended to improve access persistently flowed into private enterprises, with little or no government oversight, and access for selected groups such as "crippled" children or rural residents, Hoffman demonstrates, did not produce a right to healthcare. Private hospitals and providers refused patients (and still do). Insurance and government programmes ration eligibility on the basis of income, health condition, race or other categories. Rationing, Hoffman argues, has raised US medical costs through inefficiency, bureaucracy and medical cost-shifting.

Federal investment in hospital construction in the 1940s placed hospitals, the most expensive sites of care delivery, at the centre of the system. As hospitals, technology and costs expanded, so did the number of Americans priced out of care. Private insurance, not national health, was the peculiarly American solution. With government support, hospitals and insurers dominated US healthcare in the post-war period. Federal funding of high-tech medicine and tax policies promoting employment-based insurance eclipsed lower-cost alternative models. Federal policy favoured for-profit, fee-for-service delivery over a comprehensive primary care and public health system - a choice with a high social and economic price. The private system largely excluded the unemployed, poor, geographically isolated, chronically ill and elderly. Public calls for government intervention resulted in the creation of Medicare and Medicaid in 1965.

Hoffman pays particular attention to the intersection of the struggle for civil rights, especially hospital desegregation, and demands for health security in the 1950s and 1960s. She maps the evolution of "rights consciousness", the view that healthcare is or should be a human right, with shifts in political rhetoric and personal experiences of rationing. Social activists in the 1960s and 1970s elevated the health rights debate. In the Reagan-era recession, the middle class began to feel the pain of rationing and indignity of "patient dumping" by hospitals. Even those with comprehensive insurance lacked health security, and their rights consciousness grew with that realisation. The 2010 Patient Protection and Affordable Care Act ("Obamacare"), Hoffman concludes even-handedly, is a major accomplishment, but it retains features of past federal health programmes: rationing, public subsidies to private insurers with little oversight, and the sacrificing of universal access in the name of cost control. Americans must wait longer for universal healthcare.