According to its authors, the purpose of this book is to place the concept of “social insurance” back in the public debate over American social policy: “An earlier social insurance vision that proceeded from a common understanding of recognized risks has fragmented. The ideological underpinnings of social insurance regularly get lost in the political discussion, which takes place program by program or program feature by program feature” (p. 67). Social insurance guarantees that all members of a society are protected against risks to the loss of their income; in exchange, they contribute taxes to sustain public insurance pools. Social insurance is “the political equivalent of a contract among all American families and across generations” (p. 9).

In order to restore this vision, Theodore R. Marmor, Jerry L. Mashaw, and John Pakutka organize their book around six risks to individual/family income. They first present vignettes of each risk, such as “ill health, “involuntary unemployment,” and “the threat of early death of a family breadwinner,” and then describe its prevalence in the U.S. population. In another chapter, they discuss the competing and overlapping “philosophies” found in the design of U.S. social programs: conflicting beliefs about individual versus structural responsibility for poverty, the locus of government responsibility for program administration, and whether government should provide economic equality or only economic opportunity. The book ends with a look forward, arguing against the privatization of Social Security and Medicare. But the core of Social Insurance is comprised of six chapters that describe in detail the private and public insurance available to mitigate the six risks. At the end of each of these chapters, the U.S. experience is placed in an international perspective.

This exposition of U.S. social programs makes it clear that only the Social Security programs and Medicare truly operate as “social insurance” programs, providing protection against risks in old age. While the authors note that workers’ compensation and unemployment insurance are contributory programs viewed as earned entitlements, their data show that these programs cover risk to income in only a limited way and are far from universal. Each state sets the employer tax rate for unemployment insurance, as well as the eligibility criteria and the level and length of benefits. And states compete to attract business by having lower taxes and lower benefits. While the wage replacement varies from a high of 56% to a low of 33%, the national average is only 46%. Some jobs are simply not covered; some states have earning requirements that restrict lower wage workers. The proportion of U.S. employees covered by unemployment insurance was less than one-third in 2012; it was 60% during the 1950s (pp. 144–47).

In Chapter 5, “The Threat of Birth into a Poor Family,” the authors describe a set of fragmented policies that reduce poverty far less than do policies in all other wealthy countries; the U.S. child poverty rate is twice as high as the average of 34 wealthy countries. As the authors note, most wealthy countries provide universal children’s allowances. Americans, they say, want “to help the deserving poor, which children surely are, but we are not so sure about their parents or caretakers” (p. 72). One important omission in this chapter is a discussion of paid family leave, again a striking contrast to the situation in the rest of the wealthy world, but one that has recently risen on the U.S. policy agenda (see http://www.nationalpartnership.org/issues/work-family/paid-leave.html Alison Earle, Zitha Mokomane, and Jody Heymann, “International Perspectives on Work-Family Policies: Lessons from the World’s Most Competitive Economies” The Future of Children 21 [Fall 2011]: 191–210).

The book presents a well-written and accessible overview of the American welfare state, including the social policies created through the tax system. In one sense it is an antidote to the lack of information that, according to Suzanne Mettler, has created an uninformed and politically unengaged public (Mettler, The Submerged State: How Invisible Government Policies Undermine American Democracy, 2011). By framing the discussion in terms of the gaps in protection from the risks that life can present, the authors provide a way to demonstrate to both students and the general public that public policy affects their lives and those of their family members directly. For students, this is a connection that is crucial to engaging them in the study of politics and public policy.

Marmor, Mashaw, and Pakutka also make arguments aimed at moving U.S. social policy back toward the social insurance model of Medicare and Social Security that “respond to profound and deep-seated notions of fairness and collective responsibility” (p. 216)—or at least to preserving them. For example, they say that the only way to provide adequate unemployment insurance is to nationalize the program. They critique the Medicare Modernization Act of 2003 (MMA) and the Patient Protection and Affordable Care Act of 2010 (ACA) as moving away from that model, in their view the most sensible and equitable model for protection from the vagaries of market capitalism. The MMA encourages Medicare beneficiaries to move out of traditional Medicare and into private plans, thus allowing those plans to compete for the healthier patients and raising the cost of traditional Medicare. And similar segmentation of the population would occur if Medicare were to be replaced with medical or health savings accounts. The ACA, rather than expanding eligibility for Medicare and thus broadening the social insurance model, has instead created private markets within the program (health insurance exchanges) and separates the new populations to be covered on the basis of means-tested income categories (Medicaid vs. state exchanges). The authors also argue for small changes in contributions and benefits that will preserve the financial stability of Social Security, and against its privatization.

The authors’ case for broadening the social insurance aspects of U.S. social policy is a rationalist case; it certainly makes sense if one is ideologically supportive of universal and cost-effective public policies. But the policymaking process is not a rational one and they offer no reassurance that their prescriptions will prevail because they offer no analysis of the politics of these policies. They do not discuss ideological attacks on social programs from the Right since the 1970s, the Republican strategy of delegitimizing governmental institutions since the 1990s, nor the continuing movement to the right of the Republican Party in the last decade (see Thomas E. Mann and Norman J. Ornstein, It’s Even Worse Than it Was: How the American Constitutional System Collided with the New Politics of Extremism, 2012). Aside from citing public opinion polls that show support for Social Security and Medicare, they offer no theories of how citizens’ opinions and actions on social policy are shaped, as do Mettler and Andrea Campbell (How Policies Make Citizens: Senior Citizen Activism and the American Welfare State, 2003), and therefore how citizens can be mobilized on behalf of more equitable social policies.

While there is much to understand about how beneficiaries view social programs, it is also critical to explore the way that policies have created other constituencies with the resources to influence policy. One example is in the Medicaid program, where nursing homes, hospitals, pharmacies, managed-care and pharmaceutical companies, medical equipment manufacturers, doctors, dentists, and others constitute what Laura Katz Olson has called the “Medicaid medical industrial complex” (Olson, The Politics of Medicaid, 2010; see especially Chap. 8).

It would be important to analyze the political dynamics of future social policy even if Hillary Clinton were the president. But after the election of 2016, the importance of this kind of analysis is critical. The Secretary of Health and Human Services in the Trump administration was the sponsor of a bill repealing the Affordable Care Act and its replacement with tax provisions that would encourage the use of medical savings accounts (Robert Pear, “Tom Price, H.H.S. Nominee, Drafted Remake of Health Law,” New York Times, November 29, 2016). These proposals, which would dismantle the employer-based health insurance system, are supported by Speaker of the House Paul Ryan, who is also explicit about wanting to convert Medicaid into a block grant program with few federal regulations, as he discusses on his own Website (http://paulryan.house.gov/issues/issue/?IssueID=9978).

An analysis of the “submerged state” and “the Medicaid medical industrial complex” suggests that ideological opponents of current programs will have to do battle with the corporate interests that benefit from its continuation. Will the pharmaceutical and health insurance companies be happy with 20 million fewer patients if the ACA is repealed? Will the nursing home industry support the cuts in Medicaid as a block grant to the states? On the same day that the Republican Congressional leadership stated that the repeal of the ACA will be a first order of business in the 115th Congress (Robert Pear, “Republicans Say Repeal Will Begin in January,” New York Times, December 7, 2016), both health insurance and hospital trade associations made public statements about the need to retain central parts of the law (Reed Abelson, “Health Insurers List Demands If Affordable Care Act Is Killed,” New York Times, December 7, 2016).

Optimistically, the arguments in Social Insurance to preserve Social Security and Medicare can serve as a text for mobilization by the AARP, unions, and consumer groups working in coalition with pharmaceutical and insurance companies, hospitals, and the other “usual suspects.” If the ideologues win out over both the needs of the people and the economic interests of powerful corporations, then this book can serve as a detailed historical record of the U.S. safety net prior to its destruction.