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Why, alone among its democratic capitalist peers, does the U.S. not have national health insurance? This question has invited a range of replies; some focusing on specific historical episodes, some invoking grand political or cultural or economic explanations for the peculiar trajectory American social policy. For the most part, the historical accounts have trouble climbing from narrative to explanation; little of the scholarship on the failure of health reform in 1920 or 1935 or 1948 or 1970 or 1994 makes any substantial contribution to our larger understanding of the American welfare state and its limits. And the theoretical accounts often stumble on the descent to historical context; the largely artificial debate between "state-centered" and economic explanations, for example, rests largely on abstractions which are either not unique to the American setting (capitalism, industrialism, liberalism) or which are offered in such broad strokes that they make little sense in specific historical contexts. In explaining this "hole" in the American welfare state, it is necessary to pursue two lines of inquiry; to consider both the relative success of other American social programs during the years in which health insurance was beating at the door, and the relative success of public health insurance in other national settings. Our understanding of the American health debate of the 1940s, in other words, must in part explain both the distinct trajectory of health policy during the formative years of Social Security, and the "exceptional" character of the American welfare state.

Examines reasons for the failure of national health insurance in the US, focusing on the health debate, 1941-1948. Critical factors include a weak effort toward universal provision, limiting effects of the US political structure, & the influence of employers in shaping social policies. These factors diverted the goals of 1930s social policies, eg, the New Deal & the Social Security Act. The underlying social, legislative, economic, & political components of these factors are analyzed in detail. The emergence of private alternatives in medical care & resistance to the welfare state by corporate interests are discussed. The resulting acceptance of private health care by labor is seen as leading to a private-public compromise. Industry-specific plans also hampered universalist efforts, as did the programmatic weaknesses in the US political system, eg, a weak central government, that led to uneven & incremental reforms. Other explanations, such as cultural factors & variations on the institutionalist approach, are regarded as insufficient. It is concluded that, by defending their interests against government power, the medical & business communities set the stage for the success of future programs pushed by & targeted at special interests. T. Arnold