The result of the United States system for providing health insurance and care is that some citizens receive an abundance of high-quality care while others receive care that is poor, hard to come by, or both. This state of affairs does not fairly reflect public opinion; when surveyed, the majority of citizens express support for the idea that access to care is a right of citizenship. In a nation in which public policies relate strongly to public opinions, the failure to solve the health insurance problem is puzzling. Some analysts describe the health policy problem as economic: Health insurance products, the nature of health care as a good, and the hegemonic roles of providers and payers combine to produce the distribution of health benefits that now exists. The editors and contributors in this volume reject that view and describe health inequality as a political problem solvable with political solutions.

Healthy, Wealthy and Fair is organized in six sections and contains 12 essays and a conclusion. The initial two chapters establish the book's theme that “the health problem” is part of a larger income inequality problem. In one, the distribution of income, not wealth, is shown to be correlated with life expectancy among nations, leading the author to conclude that the distances between rich and poor in the United States result in poorly developed health policies. In the other, Lawrence Jacobs points to the link between income inequality and political inequality—business is privileged, poor people are disorganized, and labor has no coherent voice—as contributors to America's health policy problem. In a similar vein, the critiques of the market view of health care attack the market as an organizing principle for health policy. Deborah Stone argues that accepting a market view of the world means that market demand is used to replace the notion of egalitarian need, which removes from citizens, policymakers, providers, and bureaucrats the expectation that outcomes will be just, which leads to a variety of normatively bad. Mark Schlesinger argues that Americans are not as committed to the market view of health care as some might expect, marshaling evidence of opinion cleavages among groups that suggests the presence of differences of opinion on the topic.

Unions and the working class figure prominently in many nations' adoption of universal health coverage. Marie Gottschalk documents the erosion of U.S. labor's leadership in the demand for universal coverage in light of unions' having spent most of the past decade working to protect benefits of their own rank-and-file members. Constance Nathanson argues that issue framing and the politics that ensue stifle the voices of minority and other out-groups, which she contrasts to typical claims that such groups simply fail to participate due to inability to organize. She calls for government to more effectively represent those who do not demand representation, which she recognizes to be a salutary but unlikely occurrence.

The fourth section's chapters portray Congress and the courts as placing barriers to massive policy change. Mark Peterson describes a Congress that is beset by a fluid system of influential groups who need only ally with committee chairs to gain their preferred outcomes. He portrays the failures of sweeping health reforms championed by Presidents Harry Truman, Richard Nixon and Bill Clinton as casualties of this complex institutional setting. Peter Jacobson and Elizabeth Selvin paint a similar portrait of the role of the judiciary in health policymaking. They show courts to be an uncertain venue for would-be reformers, cautioning would-be reformers from seeking redress to inequality through the courts for the simple reason that they are too unpredictable.

Following the gloomy scenarios developed in the initial eight chapters of the book, the penultimate fifth section offers case studies of two recent policies that have met with success, Medicaid and school-based health centers (SBHCs). Colleen Grogan and Eric Patashnik describe the evolution of the Medicaid program, which grew from a small add-on to Medicare to the enormous health insurance coverage program it is today, and suggest that it may be the source from which broader health insurance coverage is to emerge. Current state actions designed to cut Medicaid spending notwithstanding, there is some validity to the argument that the variations seen in Medicaid—it is administered by the states with federal financial support—may provide information for future policy adjustments. However, it is unlikely that any state official would offer much praise to Medicaid, which consumes ever-growing portions of their budgets. The Elizabeth Kilbreth and James Morone essay on SBHCs suggests that an attractive target group, local constituent demand, bureaucratic involvement and support, and bipartisan political support are ingredients for successful policy changes. The SBHC success points to the value of grassroots policy organization and delivery as a basis for expanding health insurance coverage. Both Medicaid and SBHCs likewise show health coverage changes to emerge incrementally, rather than as the result of a “big bang.”

Lawrence Brown, Benjamin Page, and the editors offer health policy recommendations in the book's final section. Brown identifies a need for bold thinking but identifies numerous barriers, leading him to embrace incrementalism as the means by which change will be achieved. Page's chapter, likewise, suggests that the decentralized design of U.S. government and persistent political inequality constitute enormous barriers to widespread change. Page argues that reformers must organize, engage in incremental policy change, develop the big ideas Brown calls for so as to be prepared to seize political opportunities as they arise, and work for political reform. Morone and Jacobs end the collection with a sort of progressive call for social reformation. Noting that current disparities in wealth, health, social standing, political power, and the like are being exacerbated by economic globalization, they call for a commitment to a good community that transcends party and ideology as a necessary step toward solving the problems of inequality that are discussed in this volume.

These are well-written and nicely integrated essays. They are written, in the editors' words, to “spread the alarm” about American's poor health, presumably for opinion leaders and other nonspecialists who are attentive to public policy. Whether the book succeeds in that mission remains to be seen, but it would serve well in a specialized undergraduate course on health policy or in a graduate-level class as an example of a particular type of research and analysis or as a statement of the progressive case for widespread political and policy reform in the United States. Because it is written to persuade, it should encourage lively criticism and debate.