The Politics of Health: Diagnosing America’s Democracy through Social Rights, Advocacy, Inequalities, and Addiction

Gunnar Almgren, Health Care as a Right of Citizenship: The Continuing Evolution of Reform (New York: Columbia UP, 2017), 342 pp.

Daniel E. Dawes, The Political Determinants of Health (Baltimore, MD: Johns Hopkins UP, 2020), 216 pp.

Julia Lynch, Regimes of Inequality: The Political Economy of Health and Wealth (New York: Cambridge UP, 2019), 294 pp.

Sam Quinones, Dreamland: The True Tale of America’s Opiate Epidemic (New York: Bloomsbury Press, 2015), 368 pp.

The current state of American democracy is fraught with issues that can be examined through the lens of health policy and politics. The era of the Trump presidency has highlighted many concerning blows to health policy: from the inconsistent messaging about the pandemic, to challenges in addressing the opioid epidemic, to the contradictory partisan rallying cry to dismantle, repeal, and replace the Affordable Care Act (ACA) or “Obamacare.” The social right to health care (Almgren), the way that health care is politically determined (Dawes), the framing of health inequalities (Lynch), and the ongoing causes and management of the opioid crisis (Quinones) are key pillars through which to critically assess the policies that are implemented, not implemented, or actively dismantled—and by extension, to assess democratic rule. This review uses the lens of health policy to make sense of American democracy through examining inequalities, policies, and crises, making a compelling case for diagnosing American democracy by first taking its pulse in terms of health policy. Some books, such as Dawes’s, make direct reference to the harm that the Trump presidency has done to achieving equity, whereas others such as Lynch’s empirical study provide us with tools to better analyze health issues at hand in all democracies. What is consistent is that the central role of health policy in democracies (and globally) has never been clearer than in the pivotal year of 2020.

Gunnar Almgren’s Health Care as a Right of Citizenship introduces the critical question about the paradoxes of American exceptionalism in health care, comparing the United States to every other developed nation with a comprehensive health care system. His first chapter outlines the long history of health care reform in the United States, condensing what could be an overwhelming history in a chapter that is easily accessible for students of Health Policy and Political Science. He explains how the current U.S. health care system is a compromise that is ultimately unsustainable and argues “that the full realization of health care as a social right of citizenship is not something that is merely desirable on humanitarian grounds or even as a matter of global economic competitiveness, but that such a social right is inexorably linked to the structural requisites of democratic citizenship and democratic political institutions” (35).

Almgren outlines how the idea of a social right to health is here to stay, while at the same time critically pointing out the flaws of the ACA as they relate to exclusion of undocumented workers and others. To understand policy and partisan ideologies, Almgren draws on T. H. Marshall’s and John Rawls’s theories of citizenship and justice. He establishes the social right to health care and highlights how the ACA, building upon path dependence of employer-based health care, does not do enough to guarantee a social right to health based on citizenship: “To the extent that either health-care access or quality is experienced or viewed as a privilege afforded to the fortunate and advantaged, the collective sense of basic social equality is undermined” (103).

While Almgren provides sophisticated answers to the issues of American health care reform with excellent overviews of Marshall and Rawls on social citizenship, there is a rift between theories of democratic rights and the realities of the American policy landscape. Are presidents and policymakers ready to engage in the discourse of social rights to health care, and is it politically feasible in today’s political landscape? Or is such framing—as Lynch would argue—still a political taboo? One thing is certain: if presidents read this book, the United States might have a better chance at creating a more just health care system. Almgren’s expert analysis of the social right to health care is compelling and provides a critical appraisal of health policy and the type of health reform needed for a just society. The idea is here, but we have not yet achieved it in terms of health care policy.

Daniel E. Dawes’s book The Political Determinants of Health picks up where Almgren leaves off, albeit with a different focus, away from social rights of citizenship towards policy-making and the political determinants of health: “It is not a coincidence that certain groups of Americans experience higher premature death rates than others. It is not a fluke that some groups experience poverty for generations, blocked from attaining the American Dream. […] [I]t becomes apparent that one major factor has exacerbated the disparities in health status: our political system” (41).

Dawes begins his book with “The Allegory of the Orchard” (ch. 1), explaining centuries of complex health policy, institutional racism, lack of access to health care with an allegory of a farmer with trees planted in either fertile soil or rocky, infertile soil. He uses the tree metaphor to explain populations who are either afforded and provided with accessible goods and services (i. e., nutrients) and those who are not. In other words, health disparities could be bridged if populations were given the same access to health and services.

Dawes highlights important elements of health policy that can often be overlooked in histories of national health policy, including mental health, health equity advocates, and political backlashes to such policy efforts. He takes a more hopeful and pragmatic view of the ACA than Almgren, focusing on the behind-the-scenes working groups and actors. These advocates saw the ACA as an opportunity for achieving and advancing health equity, and reframed their message in order to get their point across and into policy. Barack Obama’s health reform on March 21, 2010, is described as “a groundbreaking piece of legislation, which advocates hoped would bring coverage to more than thirty-two million uninsured Americans. It materialized because advocates were ‘unwilling to postpone’ the creation, passage, and implementation of the country’s first inclusive and equitable health law” (127). Dawes briefly addresses the election of Donald Trump, warning that the 2016 election was a blow to health equity advocates in face of a “new government opposed to addressing racial and ethnic disparities, LGBTQ+ disparities, immigrant health issues, and climate change” (131).

Dawes’s book is essential to understand inequalities and inequities: “Health equity is the great unfinished business of our society. It has eluded the United States and other countries, owing in large part to vexing political determinants undergirded by structural racism, misogyny, and other forms of inequality” (143). This important book on equity and structural barriers transcends health care. It is, at its core, a commentary on American democracy—not only on its shortcomings, but serving also as a story of hope through the tireless work of health equity advocates.

In contrast to Almgren and Dawes, Julia Lynch takes a bird’s eye view of various rich democracies rather than focusing on the domestic inequalities of the United States—as Dawes does, or the philosophical argumentation of policy proposals in Almgren—and so she completes the picture with this more global perspective, allowing for an explicit commentary on the link between democracy and health inequalities: “Inequalities in health are every bit as troubling as the more familiar inequalities in income and wealth, even if they have received much less attention from political scientists” (3). Lynch’s starting point is the rise of inequalities in rich Western democracies. Lynch argues that politicians’ frames intertwine over the discussion on health inequality through interactions with neoliberalism: “These interactions shape how politicians frame the issue of inequality, the tools they use (and avoid using) in order to combat inequality, and ultimately their success or failure in combating rising inequality into the twenty-first century” (15).

Lynch understands health inequalities as problems that do not simply exist, but are constructed. Her book refocuses political discourse, framing, and public debate as an integral part of understanding government responses to health inequalities. Readers interested in American democracy can draw important inferences with regards to her questions of how global covenants, reports, and dialogues make their way to domestic contexts. Lynch demonstrates how health equity frames from the WHO and EU-level impact national politicians. Surprisingly, we may learn the most from what is left out: an analysis of the United States. Lynch’s book does not have an entire case study on the United States, focusing instead on England, France, and Finland. But her chapter on France outlines some questions very pertinent for scholars of American health care policy: “why did policy elites in France in the 1980s and 1990s discuss the problem of inequalities in health in a way that differs so markedly from the international consensus?” (127). The same question can be asked in the U.S. context. Importantly, she discusses the emergence of certain “taboos” in how health inequality was discussed (211-12) given the contexts of neoliberalism and political taboos around redistribution or increasing public spending, and how “neoliberal politics harms health equity […]” (217). This is highly relevant in the United States, where multiple taboos around addressing health policy issues are at play.

Sam Quinones’s Dreamland may seem an outlier compared to the three other books on health policy under review here. But Quinones’s style helps him deliver an accessible as well as heartbreaking story. In a narrative bouncing between characters in Mexico and the United States, interviews with family members touched by opioid addiction, and short historical chapters on the development of the pharmaceutical industry, Quinones’s journalism background reveals itself as he weaves together narratives converging around the current opioid crisis in the United States.

This book demonstrates the multitude of actors and forces involved in the complex crisis, from drug cartels to medical industries, to aggressive marketing to neoliberal policies, to the complexity of addiction and the humanization of the many victims of the opioid crisis in the United States. Unlike the previous three books, Quinones does not structure the book around a main academic argument. Rather, he uses various forms of narrative, stories, interviews, and journalistic discovery in very short chapters to show multiple perspectives. The message built over the course of the entire book is that any one main argument about the opioid crisis would be too narrow to capture its complexity. Readers learn about how opioids came to be so heavily prescribed, learn of the need for public health perspectives to address the problem, and that it is global in scale and entrenched in decades of trade and neoliberal growth. Quinones’s book completes a review of democracy in America: telling a tale of capitalism, economic decline, and of the nostalgia of Portsmouth, Ohio’s social agora from the 1920s to the 1990s: a private swimming pool called “Dreamland.”

Quinones’s narrative style and interviews on the painful subject of opioid addiction give us insights to which academic texts detailing policy or democracy cannot normally do justice. This means that the arc of health policy addressing addiction is not as developed, which many scholars of health policy, democracy, and inequality might desire: a comparison with the racialized crack cocaine epidemic in the 1980s and the federal government’s overwhelming response to incarcerate rather than employ public health harm reduction measures. But instead, Quinones circles back to the main characters in this work of nonfiction, underscoring the importance of community and ending the book back in Portsmouth, Ohio, on a note of hope, recovery, and overall resilience.

Assessing the nation’s democracy by measuring a range of health policies provides us with key insights into the centrality of health and health policy to American democracy. Much work lies ahead: as then President-elect, Joe Biden, stated in his victory speech, “this is the time to heal in America” (qtd. in Reston and Collinson).

Betsy Leimbigler (Freie Universität Berlin)