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The Elusive Goal of Universal Health Care in the U.S.: Organized Labor and the Institutional Straightjacket of the Private Welfare State

Published online by Cambridge University Press:  14 October 2011

Marie Gottschalk
Marie Gottschalk
Affiliation:
University of Pennsylvania
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Extract

In the late 1980s and early 1990s, national health insurance returned briefly to the political limelight with renewed calls for a single-payer health-care system that would eliminate any significant role for commercial insurers in the provision of health care. Organized labor, however, which had been a longtime proponent of national health insurance, did not warmly embrace the single-payer solution. Instead, much of the national leadership of organized labor supported some kind of employer-mandate solution that would require employers to pay a portion of their employees' health insurance premiums, thus leaving the private welfare state of job-based medical benefits largely intact.

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Articles
Information
Journal of Policy History , Volume 11 , Issue 4 , October 1999 , pp. 367 - 398
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Copyright © The Pennsylvania State University, University Park, PA. 1999

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References

Notes

1. For a view that stresses the importance of budget deficit politics in defining the parameters of the 1993-94 health-care debate, see Skocpol, Theda, Boomerang: Clinton's Health Security Effort and the Turn Against Government in U.S. Politics (New York, 1996)Google Scholar.

2. Martin, Cathie Jo, “Inviting Business to the Parry: The Corporate Response to Social Policy,” in The Social Divide: Political Parties and the Future of Activist Government, ed. Weir, Margaret (Washington, D.C., and New York, 1998), 233.Google Scholar

3. See, for example, Weir, Margaret, Orloff, Ann Shola, and Skocpol, Theda, eds., Trie Politics of Social Policy in the United States (Princeton, 1988)Google Scholar.

4. Immergut, Ellen M., “Institutions, Veto Points, and Policy Results: A Comparative Analysis of Health Care,” Journal of Public Policy 10.4 (1990):CrossRefGoogle ScholarJacobs, Lawrence R., “Politics of America's Supply State: Health Reform and Technology,” Health Affairs 14 (Summer 1995): 143–57; andCrossRefGoogle ScholarPubMedMorone, James A., “Elusive Community: Democracy, Deliberation, and the Reconstruction of Health Policy,” in The New Politics of Public Policy, ed. Landy, Marc K. and Levin, Martin A. (Baltimore, 1995)Google Scholar.

5. Steinmo, Sven and Watts, Jon, “It's the Institutions, Stupid! Why Comprehensive National Health Insurance Always Fails in America,” Journal of Health Politics, Policy and Law 20 (Summer 1995): 329–72.CrossRefGoogle ScholarPubMed

6. Martin, Cathie Jo, “Together Again: Business Government, and the Quest for Cost Control,” Journal of Health Politics, Policy and Lau 18 (Summer 1993): 359–93;CrossRefGoogle ScholarPubMedBergthold, Linda A., “American Business and Health Reform,” in Health Care Reform in the Nineties, ed. Rosenau, Pauline Vaillancourt (Thousand Oaks, Calif., 1994);Google ScholarBrown, Lawrence D., “Dogmatic Slumbers: American Business and Health Policy,” in The Polities of Health Care Reform: Lessons from trie Past, Prospects for the Future, ed. Morone, James A. and Belkin, Gary S. (Durham, N.C., 1994); andGoogle ScholarJudis, John B., “Abandoned Surgery: Business and the Failure of Health Reform,” Trie American Prospect (Spring 1995): 65–73Google Scholar.

7. Piven, Frances Fox, ed., Labor Parties in Postindustrial Societies (Cambridge, 1991), especially Frances Fox Piven, “Structural Constraints and Political Development: The Case of the American Democratic Party”;Google ScholarDubofsky, Melvyn, The State and Labor in Modern America (Chapel Hill, N.C., 1994); andGoogle ScholarRogers, Joel, “Don't Worry, Be Happy: The Postwar Decline of Private Sector Unionism in the United States,” in The Challenge of Restructuring: North American Labor Movements Respond, ed. Jenson, Jane and Mahon, Rianne (Philadelphia, 1993)Google Scholar.

8. For example, Derickson and Stevens convincingly show how organized labor played a central role in the turn toward private-sector, employment-based solutions for medical coverage with its embrace of collectively bargained health benefits as the campaign tor national health insurance sputtered in the 1940s and 1950s. This shift, in their view, subsequently posed formidable obstacles to achieving universal health care over the long run. Derickson, Alan, “Health Security for All? Social Unionism and Universal Health Insurance, 1935-1958,” Journal of American History 80 (March 1994): 1333–56; andCrossRefGoogle ScholarStevens, Beth, “Labor Unions, Employee Benefits, and the Privatization of the American Welfare State,” Journal of Policy History 2.3 (1990): 233–60. See alsoCrossRefGoogle ScholarGordon, Colin, “Why No National Health Insurance in the U.S.? The Limits of Social Provision in War and Peace, 1941-1948,” Journal of Policy History 9.3 (1997): 277–310CrossRefGoogle Scholar.

9. Jacoby, Sanford M., Modern Manors: Welfare Capitalism Since the Neu1 Deal (Princeton, 1997).Google Scholar Another notable exception is Weil, Laurence A., “Organized Labor and Health Reform: Union Interests and the Clinton Plan,” Journal of Public Health Policy 18.1 (1997): 30–48CrossRefGoogle ScholarPubMed.

10. Marmor, Theodore R., The Politics of Medicare (Chicago, 1973); andGoogle ScholarDetthick, Martha, Policymaking for Social Security (Washington, D.C., 1979)Google Scholar.

11. Stevens, “Labor Unions, Employee Benefits”; Derickson, “Health Security for All?”; and Cohen, Lizabeth, Making a Neu1 Deal: Industrial Workers in Chicago, 1919-1939 (Cambridge, 1990), especially 64–75Google Scholar and 227-30.

12. Allen, Donna, Fringe Benefits: Wages or Social Obligation? (Ithaca, N.Y., 1964), 25.Google Scholar

13. Munts, Raymond and Munts, Mary Louise, “Welfare History of the ILGWU,” Labor History 9,Google Scholar special supplement (Spring 1968), 95. See also Stevens, Beth, “In the Shadow of the Welfare State: Corporate and Union Development of Employee Benefits” (Ph.D. diss., Harvard University, 1984)Google Scholar.

14. On the early history of corporate welfare capitalism, see Berkowitz, Edward and McQuaid, Kim, Creating the Welfare State: The Political Economy of Tirentieth-Century Reform (New York, 1988);Google Scholar Jacoby, Modern Manors, esp. chaps. 1 and 2; and Dobbin, Frank R., “The Origins of Private Social Insurance: Public Policy and Fringe Benefits in America, 1920-1950,” American Journal of Sociology 97.5 (1992): 1416–50CrossRefGoogle ScholarPubMed.

15. Quadagno, Jill, The Transformation of Old Age Security: Class and Politics in the American Welfare State (Chicago, 1988); andGoogle ScholarStevens, Beth, “Blurring the Boundaries: How the Federal Government Has Influenced Welfare Benefits in the Private Sector,” in The Politics of Social Policy in the United States, ed. , Weir, Orloff, and SkocpolGoogle Scholar.

16. Garbarino, Joseph W., Health Plans and Collective Bargaining (Berkeley and Los Angeles, 1960), 249.Google Scholar

17. Lichtenstein, Nelson, “Labor in the Truman Era: Origins of the ‘Private Welfare State,’” in The Truman Presidency, ed. Lacey, Michael J. (Cambridge, 1989), 152.Google Scholar

18. Derickson, “Health Security for All?”; and Derthick, Martha, Policymaking for Social Security (Washington, D.C., 1979), 121–27Google Scholar.

19. , Derickson, “Health Security for All?” 1351–52.Google Scholar

20. “Multiemployer Trust Funds,” Employee Benefits Basics (International Foundation of Employee Benefit Plans), July 1988, 1;Google Scholar National Coordinating Committee for Multiemployer Plans (NCCMP), “Taft-Hartley, Multiemployer Health &. Welfare Plans and National Health Care Reform, report (Washington, D.C.: NCCMP, n.d.); and NCCMP, “Multiemployer Plans: A Basic Guide,” pamphlet (Washington, D.C.: NCCMP, n.d.).

21. Dunlop, John T., “Health Care Coalitions,” in Private Sector Coalitions: A Fourth Party in Health Care, ed. Jaeger, Jon B. (Durham, N.C., 1983), 10.Google Scholar

22. Under the typical Taft-Hartley plan, employers contribute some negotiated amount to a pension, health and/or welfare fund. Employers usually are not actively involved in either the administration of the plan nor the design of benefits.

23. Millis, Harry A. and Brown, Emily Clark, From the Wagner Act to Taft-Hartley: A Study of National Labor Policy and Labor Relations (Chicago, 1950), 283–332; andGoogle ScholarZieger, Robert H., American workers, American Unions, 2d ed. (Baltimore, 1994), 108–14Google Scholar.

24. Munts, Raymond, Bargaining for Health: Labor Unions, Health Insurance, and Medical Care (Madison, Wis., 1967), 10.Google Scholar

25. Estimates of how many employees were covered by union welfare funds in the 1940s vary widely. According to one estimate by the Department of Labor, such agreements covered only about 600,000 employees in 1945; by early 1947, the number had more than doubled. Joint Committee on Labor-Management Relations, “Labor-Management Relations; Report,” U.S. Senate, Report no. 986, Pt. 1, 80th Cong., 2d sess., 15 March 1948, 41Google Scholar.

26. For a detailed history of the rise and demise of the welfare and retirement fund of the United Mine Workers, see Krajcinovic, Ivana, From Company Doctors to Managed Care: The United Mine Workers' Noble Experiment (Ithaca, N.Y., 1997)Google Scholar.

27. Supplemental Views of Taft, Senators, , Ball, , Donnell, and , Jenner, “Federal Labor Relations Act of 1947,” Committee on Labor and Public Welfare, Report no. 105, U.S. Senate, 80th Cong., 1st sess., 17 April 1947, 52Google Scholar.

28. Committee on Education and Labor, “Labor-Management Relations Act, 1947,” Report no. 245, U.S. House, 80th Cong., 1st sess., 11 April 1947, 30.Google Scholar

29. Committee on Education and Labor, “Labor-Management Relations Act, 1947,” Report no. 245, U.S. House,80th Cong., 1st sess., 11 April 1947, 29.Google Scholar One business executive charged that these funds would permit unions “to build up enormous sums of tax-free money which could be administered, invested and distributed as union leaders saw fit.” Testimony of Campbell, Rolla D., “Amendments to the National Labor Relations Act,” vol. 2, Committee on Education and Labor, U.S. House, 80th Cong., 1st sess., February-March 1947, 634–35Google Scholar.

30. Supplemental Views, Report no. 105, 52.

31. See Munts, Bargaining for Health, chap. 1; Hartley, Fred A. Jr, Our New National Labor Policy (New York, 1948);Google Scholar, Millis and , Brown, From the Wagner Act to Taft-Hartley, 564; andGoogle ScholarHartmann, Susan M., Truman and the 80th Congress (Columbia, Mo., 1971)Google Scholar.

32. Supplemental Views, Report no. 105, p. 52.

33. , Millis and , Brown, From the Wagner Act to Taft-Hartley, 567.Google Scholar

34. Committee on Labor and Public Welfare, “Federal Relations Act of 1947,” Report no. 105, pt. 2, Minority Views, 80th Cong., 1st sess., 22 April 1947, 23.Google Scholar

35. George Meany, letter to National and International Unions, State Federations, City Central Bodies, Federal Labor Unions, and Regional Organizers, January 7, 1953, AFL, AFL-CIO Department of Legislation, 1906-1978 (hereafter, AFL-CIO Department of Legislation Collection), George Meany Memorial Archives, Silver Spring, Md., Box 24, Folder 39, “Health.”

36. See, for example, Joint Committee on Labor-Management Relations, “Labor-Management Relations,” Report No. 374, U.S. Senate, 81st Cong., 1st sess., 13 May 1949, esp. 5 and 39Google Scholar.

37. Munts, Bargaining for Health, chaps. 5 and 6; Root, Lawrence S., Fringe Benefits: Social Insurance in the Steel industry (Beverly Hills, Calif., 1982).Google Scholar In 1949, health and welfare issues were central in 55 percent of all strikes; in the first half of 1950, 70 percent of all strikes were over these issues. , Stevens, “In the Shadow of the Welfare State,” 129Google Scholar.

38. See, for example, the testimony of Smethurst, Raymond S., counsel of the National Association of Manufacturers, and other business representatives in “Operation of the Labor-Management Relations Act,” parts 1 and 2, Joint Committee on Labor-Management Relations, U.S. Congress, 80th Cong., 2d sess., May-June 1948Google Scholar.

39. Biemiller, Andrew J., memo, re: Additional subject to discuss with President Meany, 13 January 1954,Google Scholar AFL-CIO Department of Legislation Collection, Box 25, File 14, “Health, Education, and Welfare, Department of”; and Andrew J. Biemiller, memo to George Meany, Re: Proposed Legislation on Health and Welfare Funds, 28 January 1954, AFL-CIO Department of Legislation Collection, Box 85, Folder 8, “Memoranda to George Meany, 1954.”

40. Bert Seidman, former director of the department of social security, AFL-CIO, Interview, Washington, D.C., 13 June 1996; and Bert Seidman, memo to Al Barkan et al., 21 May 1970, re: Health and Welfare Trusts and National Health Insurance, attachment, p. 2, AFLCIO Department of Legislation Collection, Box 25, Folder 24, “Health Insurance.”

41. NCCMP, “Taft-Hartley, Multiemployer Health & Welfare Plans,” p. 2;Google ScholarU.S. General Accounting Office, “Employer-Based Health Plans; Issues, Trends, and Challenges Posed by ERISA” (Washington, D.C., 1995), 39;Google Scholar “Health Care ‘Reform’ Should NOT Come at the Expense of the Building Trades!!!,” mimeo, n.d., received from James S. Ray, legislative representative, NCCMP; and Laborers' Health & Security Fund of America, “Cost Shifting: Who Shoulders the Burden of the Health Care Crisis?” report (Washington, D.C.: Laborers' Health & Safety Fund, n.d.).

42. Purcell, Leo J., letter to Robert Georgine, 28 January 1991,Google Scholar Personal Files of Robert McGarrah, director of public policy AFSCME headquarters, Washington, D.C. (hereafter McGarrah Papers).

43. Berliner, Howard S., “Payment for Uncompensated Hospital Care in New Jersey: Impact on Union Health and Welfare Funds,” report (Washington, D.C: Laborers' National Health and Safety Fund, March 1989), 5.Google Scholar

44. For example, the building trades in Massachusetts were at the center of one of the most high profile and successful campaigns against the perceived corporate excesses of the Reagan years, the 1988 battle to preserve a state law governing wages on publicly funded construction sites. Erlich, Mark, Labor at the Ballot Box: The Massachusetts Prevailing Wage Campaign of 1988 (Philadelphia, 1990)Google Scholar.

45. Crenshaw, Albert B., “The Aim to Be Letter Perfect; ULLICO Repositions for Growth and ‘A’ Insurance Rating,” Washington Post, 11 July 1994, Fl; andGoogle Scholar“Ullico Inc.,” Washington Post, 18 April 1995 F 47Google Scholar.

46. Goozner, Merrill, “Health Care Debate Splits Union Ranks,” Chicago Tribune, 18 February 1991, 1Google Scholar

47. McGarrah, Robert, director of public policy, AFSCME, Interview, Washington, D.C, 5 June 1996.Google Scholar

48. McGarrah, Interview; and Ray, James S., legislative representative, NCCMP, Interview, Washington, D.C, 13 June 1996Google Scholar.

49. Ray, Interview.

50. Ray, Interview; J. Peter Nixon, senior policy analyst, SEIU, Interview, Washington, D.C., 3 June 1996; Claudia Bradbury St. John, former senior health policy specialist, AFLCIO, Interview, Washington, D.C., 7 June 1996; and J. Peter Nixon, memo to Hal Alpert, president of Local 531 of the Service Employees International Union, re: Health Care Reform, 2 March 1994, Personal Files of J. Peter Nixon (hereafter Nixon Papers), SEIU headquarters, Washington, D.C.

51. Robert McGarrah, “Notes Re: 1/31/91 Meeting of the Health Care Committee,” McGarrah Papers; Frieden, Joyce, “Unions Rev Up Health Reform Engines,” Business and Health 9 (August 1991), 4244; andGoogle ScholarPubMedGordon, Suzanne, “AFL-CIO Steps Backwards on National Health Insurance,” Labor Notes (April 1991), 1Google Scholar.

52. After Bill Clinton was elected president in 1992, the ILGWU did begin to qualify its support of national health insurance and to indicate its willingness to support health-care proposals based on the employer mandate and the preservation of the Taft-Hartley arrangements. See Gottschalk, Marie, The Shadow Welfare State: Business and U.S. Health-Care Policy (Ithica, N.Y.: forthcoming), chap. 7Google Scholar.

53. , Munts and , Munts, “Welfare History,” 96.Google Scholar

54. Levitan, Sar A. and Cooper, Martha R., Business Lobbies: The Public Good and the Bottom Line (Baltimore, 1984), chap. 5.Google Scholar

55. Fox, Daniel M. and Schaffer, Daniel C., “Health Policy and ERISA: Interest Groups and Semipreemption,” Journal of Health Politics, Policy, and Law 14 (Summer 1989), 240.CrossRefGoogle ScholarPubMed

56. Farrell, Margaret G., “ERISA Preemption and Regulation of Managed Care: The Case for Managed Federalism,” American Journal of Lau1 & Medicine 23.2 and 3 (1997): 251–89.Google ScholarPubMed

57. The “Health Insurance Portability and Accountability Act of 1996,” commonly known as the Kennedy-Kassebaum bill, does subject self-insured plans, which were protected from state oversight due to ERISA, to some new broad federal regulations regarding medical underwriting practices. It also forbids self-insured and nonself-insured group health plans from limiting the health coverage they offer to new employees with preexisting conditions. The HIPAA did not significantly alter the ERISA preemption, however. Reforming States Group, “Balanced Federalism and Health System Reform,” Health Affairs (May-June 1998): 181–91Google Scholar.

58. , Fox and , Schaffer, “Health Policy and ERISA,” 243.Google Scholar

59. See, for example, George J. Pantos of the ERISA Industry Committee (ERIC), “ERISA Improvements Acts of 1979, Committee on Labor and Human Resources, U.S. Senate, 96th Cong., 1st sess., February 1979, 522. ERIC, which counts dozens of firms among its membership, is the main vehicle among employers to defend an expansive ERISA preemption.

60. Chirba-Martin, Mary Ann and Brennan, Troyen A., “The Critical Role of ERISA in State Health Reform,” Health Affairs 13 (Spring 1994): 142–56; andGoogle ScholarPubMedParmet, Wendy, “Regulation and Federalism: Legal Impediments to State Health Care Reform,” American Journal of Law and Medicine 19.1 and 2 (1993): 132–40.Google ScholarPubMed For a slightly different view, see Grogan, Colleen M., “Hope in Federalism? What Can the States Do and What Are They Likely To Do?” Journal of Health Politics, Policy and Law 20.2 (Summer 1995): 477–84CrossRefGoogle ScholarPubMed.

61. By the early 1990s, nearly 60 percent of Americans who were insured through their employers were covered by such plans. Gladwell, Malcolm, “When Health Plan Changes Leave Employees Vulnerable; AIDS Case Targets Federal Self-insurance Law,” Washington Post, 20 August 1992, A 1Google Scholar.

62. Robert Georgine, president of the building and construction trades department of the AFL-CIO, “Health Care Reform,” Part 5,Google Scholar Subcommittee on Health and the Environment of the Committee on Energy and Commerce, U.S. House, 103d Cong., 1st sess., November 1993, 1035.

63. Pemberton, Carolyn and Holmes, Deborah, eds., EBRI Databook on Employee Benefits, 3d ed. (Washington, D.C, 1995), 291;Google ScholarFreudenheim, Milt, “Employers Winning Wide Leeway to Cut Medical Insurance Benefits,” New York Times, 29 March 1992, A 1; andGoogle ScholarTreaster, Joseph B., “Protecting Against the Little Risks,” New York Times, 31 December 1996, Dl.Google Scholar

Recently, small businesses have lobbied fiercely for controversial legislation that would in effect greatly extend the ERISA umbrella by permitting national membership organizations, such as trade associations, to ban together to set up self-insured plans called multiple employer welfare associations (MEWA's) that would not be subject to state-level insurance regulations. Fawell, Harris W., “Squeezing Small Business,” Washington Post, 16 April 1997, A17.Google Scholar See also Reforming States Group, “Balanced Federalism.”

64. Research Institute of America, Inc., Executive Compensation Alert, 15 May 1991, online database.Google Scholar

65. Notably, in its 1987 Piiot Life decision, the Supreme Court held that state laws setting standards for the processing of health benefits claims by insurance companies were preempted by ERISA. States had attempted to use these laws to provide employees with legal recourse for what they saw as an unfair denial of claims. Research Institute of America, Inc., Executive Compensation Alert; and Milt Freudenheim, “Employers Winning Wide Leeway to Cut Medical Insurance Benefits.”

66. For example, employers have used the ERISA preemption to mount successful challenges to prevailing wage laws, state standards for the certification or training of apprentices, and state mandates in the area of workers' compensation coverage.

“Businesses Await Ruling on Unified Self-insured Plans,” HR Focus, April 1993, 1.Google Scholar

Robert Georgine of the AFL-CIO testified in 1991 that federal legislation was needed to restrict ERISA's preemption of state laws in these three specific areas unrelated to health benefits. However, he did not advocate scrapping the ERISA preemption altogether and was forced to concede the AFL-CIO had been a longtime defender of a broad ERISA preemption. Research Institute of America, Inc., Executive Compensation Alert, 15 May 1991Google Scholar.

67. Georgine, Robert, “ERISA Improvements Act of 1979,” Committee in Labor and Human Resources, U.S. Senate, 96th Cong., 1st sess., February 1979, 281Google Scholar; and Fox and Schaffer, “Health Policy and ERISA”

68. Pear, Robert, “Court Approves Cuts in Benefits in Costly IIIness,” New York Times, 27 November 1991, Al;Google ScholarPear, Robert, “U.S. to Argue Employers Can Cut Health Coverage,” Neu.1 York Times 16 October 1992, A18; andGoogle ScholarStoddard, Thomas D., “Now You're Insured, Now You're Not,” New York Times, 23 May 1992, A 23Google Scholar.

69. Goldberg-Hiller, Jonathan, “The Limits to Union; Labor, Gays and Lesbians, and Marriage in Hawaii,” paper presented at the annual meeting of the American Political Science Association, Boston, 3-6 September 1998.Google Scholar

70. Michelini, Alex, “Union's $1 M AIDS Penalty,” New York Daily News, 15 December 1995, 16Google Scholar; and Oppel, Richard A. Jr, “Health-Benefits Ruling Poses Risk for Small Firms; EEOC Decision Would Not Allow Discriminatory Coverage,” Dallas Morning News, 11 June 1993, Dl.Google Scholar

71. Recently, they have been joined by HMO's, which have been attempting to use the ERISA preemption to shield themselves against lawsuits. Farrell, “ERISA Preemption and Regulation of Managed Care”; and Pear, Robert, “H.M.O.'s Using Federal Law to Deflect Malpractice Suits,” New York Times, 17 November 1996, sec. 1, p. 24Google Scholar.

72. I am indebted to Professor Alan Draper of St. Lawrence University for this metaphor.

73. Maclntyre, Duncan M., Voluntary Health Insurance and Rate Malting (Ithaca, N.Y., 1962), 111.Google Scholar

74. In 1946, some 32 million Americans had some form of health insurance. Just two years later, the figure stood at 53 million. And by 1951, 77 million Americans were covered. Fein, Rashi, Medical Care, Medical Costs: The Search for Health Insurance Policy (Cambridge, Mass., 1986), 23Google Scholar.

75. , Garbarino, Health Plans and Collective Bargaining, 228.Google Scholar

76. , Maclntyre, Voluntary Health Insurance and Rate Making, 237, 252.Google Scholar

77. , Gordon, “Why No National Health Insurance in the U.S.?” 302.Google Scholar

78. , Garbarino, Health Plans and Collective Bargaining, 228–32.Google Scholar

79. , Gordon, “Why No National Health Insurance in the U.S.” 287.Google Scholar

80. Indeed, a 1956 study by the New York State Department of Insurance described therating practices of some insurance carriers as “arbitrary,” “capricious,” and involving “discriminatory opportunism.” , Maclntyre, Voluntary Health Insurance and Rate Making, 103. See alsoGoogle ScholarStone, Deborah A., “The Struggle for the Soul of Health Insurance,” Journal of Health Politics, Policy, ami Law 18 (Summer 1993)Google ScholarPubMed.

81. Stone, “The Struggle tor the Soul of Health Insurance”; and Reinhardt, Uwe E., “How the Devil Subverted the Nation's Soul: An Allegory About American Health Policy,” in Social Insurance Issues for the Nineties, Proceedings of the Third Conference of the National Academy of Social Insurance, ed. Water, Paul N. Van De (Dubuque, Iowa, 1992), 85Google Scholar.

82. Stone, Deborah A., “AIDS and the Moral Economy of Insurance,” American Prospect, (Spring 1990), 72.Google Scholar

83. Coddington, Dean C., Keen, David J., and Moore, Keith D., “Cost Shifting Overshadows Employers' Cost-Containment Efforts,” Business and Health (January 1991) 45–46.Google Scholar

84. , Judis, “Abandoned Surgery,” 66.Google Scholar

85. Congressional Research Service, Cost and Effects of Extending Health Insurance Coverage (Washington, D.C., 1988), 46, cited inGoogle ScholarBlendon, Robert J. and Hyams, Tracey Stelzer, eds. Reforming the System: Containing Health Care Costs in an Era of Universal Coverage (New York, 1992), fig. 12, p. 11Google Scholar.

86. This is not to argue that the small-business sector represents an untapped font of progressivism on health policy or other social issues, nor to absolve the small-business sector ot any responsibility for the health-care crisis. Moreover, it is not my intention here to minimize unduly the important role that conservative ideology played in the small-business sector's opposition to the Clinton plan and other social welfare schemes.

87. Gottschalk, Marie, “The Missing Millions: Labor, Business, and the Defeat of Clinton's Health Security Act,” Journal of Health Politics, Policy, and Law 24 (June 1999).CrossRefGoogle ScholarPubMed

88. Barbara Markham Smith, former legislative aide to the longtime single-payer advocate Rep. Jim McDermott (D-Wash.), Interview, Washington, D.C., 24 June 1996; and Sara Nichols, former staff attorney, Public Citizen, Interview, Washington, D.C., 13 June 1996.

89. David Abernethy, former majority staff director, Subcommittee on Health of the Committee on Ways and Means, U.S. House of Representatives, Interview, Washington, D.C., 14 June 1996.

90. His remarks were not for attribution.

91. Ray, Interview; and SEIU, Industrial and Allied Update, Fall-Winter 1993, 9Google Scholar.

92. Georgine, Robert, chairman of the National Coordinating Committee for Multiemployer Plans (NCCMP), “Hearings on Health Care Reform Act,” Part 5,Google Scholar House Subcommittee on Health and the Environment of the Committee on Energy and Commerce, 103d Cong., 1st sess., November 1993, 103.

93. Parks, James B., “Kirkland: Undaunted Unionists ‘Agents of Change’,” AFL-CIO News, 18 October 1993.Google Scholar

94. McGarrah, Intetview; and Robert McGarrah, memo to Gerald McEntee, 22 April 1994, re: Meeting with Magaziner, McGarrah Papers, Box 4, “National Health Care Reform” folder.

95. Testimony of Jerry J. Jasinowski, president of NAM, “Health Care Reform Proposals,” vol. 7, Subcommittee on Health ot the Committee on Ways and Means, U.S. House, 103d Cong., 1st sess., 28 October, 2 November, and 4 November 1993, 403; and , Skocpol, Boomerang, 66Google Scholar.

96. Consumers Union, “The Clinton Health Care Act: What Will It Mean for Consumers?” rev. (Washington, D.C., January 1994), 26; andGoogle Scholar Gail Shearer, director of health policy analysis, Consumers Union, Interview, Washington, D.C., 7 June 1996.

97. Abetnethy, Interview.

98. G. Lawrence Atkins, coordinator, Corporate Health Care Coalition, Interview, Washington, D.C., 6 June 1996; and Karrh, Bruce, vice-president of DuPont Co., “Health Care Reform Act,” Part 6,Google Scholar Subcommittee on Health and the Environment of the Committee on Energy and Commerce, U.S. House, 103d Cong., 1st sess., November-December 1993, 66-79 and 707.

99. Ray, Interview; and Georgine, Robert, “Health Care Reform Act,” Part 5,Google Scholar Subcommittee on Health and the Environment of the Committee on Energy and Commerce, U.S. House, 103d Cong., 1st sess., November 1993, 103-5.

100. Wise, D., “What Happens to ERISA Under Health Care Reform?” Business & Health, 11.12 (1993), 53–56.Google ScholarPubMed

101. In the words or James Ray of the NCCMP, unions with Taft-Hattley funds “went berserk” over the Mitchell proposal and were proud to have brought it down. Ray, Interview.

102. Alan Reuther, legislative director, UAW, Interview, Washington, D.C., 7 June 1996.

103. See, for example, Sweeney, John J., editorial, Industrial and Allied Update (Spring-Summer 1991).Google Scholar In 1991, Sweeney tried to get the Ohio AFL-CIO to rescind its support of legislation that would create a single-payer system in Ohio.

104. Gerald M. Shea, assistant to the president for governmental affairs, AFL-CIO, Interview, Washington, D.C., 13 June 1996.

In the 1993-94 period, the national leadership of some unions that had once been ardent single-payer supporters and the national leadership of the AFL-CIO began pressuring labor's single-payer advocates at the state level to change their tune. Boatman, Glen, “AFSCME's Switch to ‘Managed Competition’ Upsets Single-payer Movement in Ohio,” Labor Notes, March 1993, 5;Google ScholarBoatman, Glen, “AFL-CIO Leadership Is Failing in Its National Health Care Campaign,” Labor Notes, February 1991, 11; andGoogle Scholar“Healthy States?” Health Letter (Public Citizen's Health Research Group) 8, (July 1992): 89Google Scholar.

105. See, for example, Nancy Donaldson and Ned McCulloch to Bob Welsh and Gerry Shea, 2 October 1993, Nixon Papers, “The Clinton Plan-SEIU Materials” folder.

106. For a development of this point, see Skowronek, Stephen, Building a New American State: The Expansion of National Administrative Capacities, 1877-1920 (Cambridge, 1982), especially 89CrossRefGoogle Scholar and 13; Weir, Margaret, Orloft, Ann Shola, and Skocpol, Theda, eds., The Politics of Social Policy in the United States (Princeton, 1988); andGoogle ScholarWeit, Margaret and Skocpol, Theda, “State Structures and Social Keynesianism,” International Journal of Comparative Sociology 24 (1983): 429Google Scholar.

107. Dobbin, “The Origins of Private Social Insurance,” 1420. See also Weir, Margaret, Politics and Jobs: The Boundaries of Employment Policy in the United States (Princeton, 1992), especially 16Google Scholar.

108. Orren, Katen and Skowronek, Stephen, “Beyond the Iconography of Order: Notes for a New Institutionalism,” in The Dynamics of American Politics: Approaches and Interpretations, ed. Dodd, Larry C. and Jillson, Calvin (Boulder, Colo., 1993); andGoogle ScholarSmith, Rogers M., “Beyond Tocqueville, Myrdal, and Hartz: The Multiple Traditions in America,” American Political Science Review 87 (September 1993): 549–66CrossRefGoogle Scholar.

109. Steinmo, Sven and Thelen, Kathleen, “Historical Institutionalism in Compatative Politics,” in Steinmo, Sven, Thelen, Kathleen, and Longstreth, Frank, eds., Structuring Politics: Historical institutionalism in Comparative Analysis (Cambridge, 1992), 3.CrossRefGoogle Scholar Or as David B. Truman reminds us, institutions do not “prescribe all the meanderings of politics.” Rather, they “mark some of its limits” and “designate certain points through which it must flow.” , Truman, The Governmental Process (New York, 1953), 322Google Scholar.

110. For a good discussion of the intersection between political economy and historical institutionalism, see Pontusson, Jonas, “From Comparative Public Policy to Political Economy: Putting Political Institutions in Their Place and Taking Interests Seriously,” Comparative Political Studies 28 (April 1995): 117–47CrossRefGoogle Scholar.

111. Or what North eloquently calls the “fumbling efforts” political actors make in “deciphering their environment.” North, Douglass C., Institutions, Institutional Change and, Economic Performance (Cambridge, 1990), 23CrossRefGoogle Scholar and 22, respectively.

112. Weir, Margaret, “American Politics and the Future of Social Policy,” in The Social Divide: Political Parties and the Future of Activist Government, ed. Weir, Margaret (Washington, D.C., 1998), 525.Google Scholar

113. For more on the Canadian case, see Taylor, Malcolm G., Health Insurance and Canadian Public Policy: The Seven Decisions That Created the Canadian Health Insurance System (Montreal, 1978);Google ScholarMaioni, Antonia, “Explaining Differences in Welfare State Development: A Comparative Study of Health Insurance in Canada and the United States” (Ph.D. diss., Northwestern University, 1992);Google ScholarChandler, William M., “Canadian Socialism and Policy Impact: Contagion from the Left?” Canadian Journal of Political Science 10 (December 1977): 755–80; andCrossRefGoogle Scholar Marie Gottschalk, The Shadoiv Welfare State, chap. 2.

114. Schattschneidet, E. E., The Semi-Sovereign People: A Realist's View of Democracy in America (New York, 1960), 68.Google Scholar