Unaffordable

Reviewed by: Unaffordable: American Healthcare from Johnson to Trump by Jonathan Engel Andrew T. Simpson Jonathan Engel. Unaffordable: American Healthcare from Johnson to Trump. Madison: University of Wisconsin Press, 2017. x + 285 pp. $34.95 (978–0–299–31410–1). Jonathan Engel’s Unaffordable: American Healthcare from Johnson to Trump provides a lively tour through the last half century of American health care and the crisis of cost that has come to define its current state. The book, which is written in an accessible manner, is a good companion for readers with limited familiarity about how health care is paid for and delivered. Engel argues that the American health care system is really not a coherent system at all, but instead is a “coordinated network of public and private providers spread throughout the country,” which is both purposefully irrational and “uniquely dysfunctional” (p. 3). Unaffordable unfolds in a roughly chronological fashion and begins with an overview of the wide array of programs that sprang to life as part of the Great Society that attempted to link better health outcomes, economic opportunity, and social mobility. Engel’s brief discussion of Neighborhood Health Centers is particularly helpful and reflects a growing interest in community medicine by historians of medicine and scholars of social policy.1 He also highlights the persistent concerns with the supply of health professionals including the growth of the allied health professions and the increasing dependence on foreign medical graduates throughout the late 1960s and 1970s. Another goal of Unaffordable is explaining the rise of for-profit and not-for-profit management structures that emerged to control costs and extract excess revenue from the delivery of health care. Here, Engel devotes significant space to the history of Health Maintenance Organizations, Professional Standards Review Organizations, and the mechanics of managed care. He also focuses on the rise of the for-profit hospital and pharmaceutical industries. His focus on the growth of for-profit hospitals during the 1980s and 1990s is particularly welcome—this is an area that needs further study, especially as it relates to how growing fears of the for-profit hospital industry shaped the behavior of their not-for-profit competitors. Finally, Unaffordable covers the significant health care reform efforts that dominated the final decades of the twentieth century and the first decades of the current one. For example, Engel’s discussion of the Clinton Plan focuses on the concept of “managed competition,” the unwillingness of moderate Democrats and entrenched health care interests to jettison their own hard-won interests in favor of more sweeping reforms, and how opponents of the plan were able to use it as a political weapon. Echoing the assessments of other scholars, he also notes that the incrementalist nature of the reform, when combined with a lackluster and, at times, wonky, sales campaign helped to seal its fate with the general public.2 His [End Page 139] discussion of the Affordable Care Act balances the law’s strengths and weaknesses, especially “its inability to provide comprehensive coverage for most middle-class citizens” (pp. 207–208). Finally, by placing several chapters of additional context between the discussion of each major attempt at health care reform, including efforts to change Medicare under President George W. Bush, the reader can see how the legacy of earlier health care reforms efforts has shaped the current politics of health care and has, perhaps, to the detriment of subsequent reform efforts, often involved the reappearance of many of the same actors. Some historians may quibble with Engel’s choice of sources, which are primarily drawn from medical or health policy journals and popular publications like Forbes, Washington Monthly, or The Nation. While a few important works by historians of medicine are mentioned in the notes, a more comprehensive connection to the existing historiography would make the book more useful as a classroom reference, especially for an undergraduate audience. It might also help to balance out the tendency of these types of sources to focus on large urban settings rather than fully reflect how disparate geographies have shaped the development of the modern health care system across the entire country. Ultimately, the strength of Unaffordable is its readability and the

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