Wages of Sickness

Review: Melissa Thomasson on Beatrix Hoffman

Beatrix Hoffman, The Wages of Sickness: The Politics of Health Insurance in Progressive America. Chapel Hill: University of North Carolina Press, 2001. xiii + 261 pp. $39.95 (cloth), ISBN: 0-8078-2588-3; $17.95 (paper), ISBN: 0-8078-4902-2.

Reviewed for EH.NET by Melissa A. Thomasson, Department of Economics, Miami University.
Published by EH.NET, July 2001.

Proposals for universal health insurance coverage in the United States have been defeated several times over the course of the twentieth century -- the failure of Bill Clinton to enact comprehensive health insurance reform is a failure shared by FDR and Harry Truman. In each instance, proponents of compulsory insurance failed to overcome strong opposition, particularly from physicians and insurance companies. Even earlier in the twentieth century, the American Association for Labor Legislation (AALL) faced similar opposition to the compulsory health insurance bills it sponsored in several states, and none were ever enacted. Beatrix Hoffman, an assistant professor of history at Northern Illinois University, examines the failure of the compulsory healthinsurance movement in one of these states, New York, to provide a glimpse into Progressive Era health politics. In so doing, she reveals how Progressive failures solidified interest group opposition to state-sponsored health insurance, and argues that this opposition may have doomed future attempts to provide national insurance.

Hoffman tells the story of the American Association for Labor Legislation's failure to enact compulsory health insurance in New York over the period 1916-1920. While she is not the first to examine their state-level proposals for health insurance during the period, she offers a fresh perspective on New York's experience, and uncovers interesting information about the forces that shaped interest group politics in the Progressive Era.

The book is organized into eight chapters and an epilogue. In the first chapter, Hoffman provides information about the situation of the typical wage earner in the Progressive Era. Many workers had little money to pay for medical care and had only a "patchwork of protection" that sheltered them from economic insecurity in the event of illness. Missing from the chapter (and from most of the book) is a discussion of the effectiveness of medical care and the demand for health insurance in general. While most of the information provided in the chapter is fairly well known, it sets the stage for readers unfamiliar with the period.

Hoffman's real contributions come after the first chapter. The second and third chapters discuss the manner in which the AALL developed the foundation for their compulsory insurance programs. Both chapters are well researched and very detailed. For example, Hoffman brings to light the substantial role of Olga Halsey, a young Wellesley graduate with a graduate degree from the London School of Economics, who worked in London doing research on national health insurance.

Hoffman also provides a broader institutional perspective on the AALL's development of health insurance than do other works on the subject. In the second chapter, Hoffman first notes the failure of the AALL to court groups that would be affected by their proposed legislation. This oversight is a central theme in the book -- chapter 4 is entitled "The Worst Insult to the Greatest Profession," and discusses how the AALL failed to include physicians in the development of their model legislation. In chapter 5, Hoffman similarly discusses how the needs and/or anxieties of employers and commercial insurance companies were barely considered and their opposition seriously underestimated. Both groups were liable to bear considerable costs associated with the legislation. Employers would be required to contribute to the cost of the insurance program, yet AALL reformers erroneously believed that employers would come to support the bill (as they had workers' compensation laws). Despite the fact that commercial insurance companies were also a potentially serious source of opposition, the AALL included burial insurance as one of their proposed benefits, thus threatening one of the most profitable lines of commercial insurance companies.

Hoffman also pays close attention to the role of other groups in opposing or supporting the AALL's efforts. She demonstrates that even seemingly homogeneous groups had subgroups that thought very differently about compulsory insurance. In chapter 6, she examines how organized labor viewed the proposed legislation. Samuel Gompers publicly opposed compulsory insurance, yet Hoffman shows how Gompers' opinion was not shared by all labor groups. In chapter 7, she provides a novel look at how the AALL's proposal of maternity benefits for women workers and the wives of insured workers divided women in the Progressive Era. The debate overmaternity benefits is set against a rich political backdrop; Hoffman describes the political power structure in New York and identifies competing interest groups. While some women clearly supported the legislation, others opposed it for a variety of reasons. Opponents included Florence Kelley, a noted activist, who believed that maternity benefits would tax poorly paid single women and force pregnant women into the labor force. Other women (such as women printers) opposed any sort of maternalist legislation that may have dictated the terms of their employment.

Overall, Hoffman's book provides a detailed look at the various interest groups that both supported and opposed plans for compulsory health insurance in New York. She identifies competing interest groups and subgroups, and clearly demonstrates the AALL's failure to account for strong opposition. While her book is well-researched and detailed on these points, it tends to understate the fact that many Americans were relatively indifferent to the AALL's efforts, and that this many have seriously impacted the organization's success. As Odin Anderson notes, "the fight was between individual giants on Olympus, to which the general public seemed to pay only passing interest" (Anderson, The Uneasy Equilibrium: Private and Public Financing of Health Services in the United States, 1875-1965, New Haven, 1968, p. 87). Keeping this in mind, Hoffman's book sheds light on a complex issue and is interesting and informative for people interested in Progressive Era reforms.

Melissa Thomasson is assistant professor of economics at Miami University (Oxford, Ohio) and does research on the economic history of health care and health insurance.

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Posted: 12 July 2001