These two ambitious books tackle one of the great analytic and practical policy puzzles facing any observer of American society. The American health-care system looks like the quintessence of national exceptionalism, and making sense of that exceptionalism has occupied the energy of a generation of scholars. Two features make the American system stand out by comparison with the health-care systems of other advanced capitalist democracies: It is stunningly expensive, and it fails to meet the health-care needs of a significant proportion of the population. The figures are widely rehearsed: The United States spends about 15% of its gross domestic product on health care; even the comparatively profligate French spend only about 10%, and most countries of the Organization for Economic Co-operation and Development spend much less. Meanwhile about 46 million Americans (15% of the population) have no health-care insurance coverage. (The particular figures cited here are from Differential Diagnoses, pp. 5–6, but the order of magnitude has been plain for a generation.) The problem is almost certainly getting worse by the day: All projections point to continuing cost increases; the economic crisis that we are now entering will undoubtedly further shred the American system of workplace-based health insurance and leave millions more Americans without coverage.

Gerard W. Boychuk and Paul V. Dutton have now made distinguished contributions to the literature seeking to make sense of this policy fiasco, though they approach the task in rather different ways and end up with different conclusions. To put it simply—maybe too simply for books that are models of subtle scholarship—Boychuk dissents from the predominant explanations of American exceptionalism; Dutton dissents from the thesis of exceptionalism itself.

Boychuk's study has a familiar starting point: Why are the United States and Canada different in respect to their health insurance arrangements? That starting point links, of course, to a wider literature that has engaged in a kind of extended “most similar” comparison of the two nations. National Health Insurance in the United States and Canada begins with a skeptical review of the existing explanatory literature on health care, notably of accounts that stress differences in political culture, differences in the institutional structure of policymaking, and—the latest incarnation of the institutional tradition—claims about path dependency and veto points that are at the heart of historical institutionalism. In essence, his case is that “exceptionalism” does not work well on any of these dimensions. The key difference is more historically specific, and it concerns the divergent forces driving policy change in the two systems. In the United States, Boychuk argues, much of the resistance to reform, especially reform that would extend federal control of the health insurance system, has been a more or less coded form of racism; in Canada, the force driving health insurance reform has been the felt need to link health care to a conception of national citizenship, especially in the face of Quebec separatism. This argument is then worked out in an extended series of analytic histories of reform episodes, failed and successful, in the two countries. They stretch in the American case, for instance, from the proposals of the Progressive era to the failure of the Clinton reforms in the 1990s.

This is a self-consciously iconoclastic argument; it is done with great scholarly care, and it makes stimulating, challenging reading. But it nevertheless fails to quite convince, on three grounds. First, the great inspiration for this view of the American health policy system as race driven is obviously Gunnar Myrdal (who is invoked on p. 4). But whereas a Myrdal-inspired view of things makes a lot of sense for, say, the failure of the reform efforts of the Roosevelt and Truman eras, the attempt to shape a similar argument for the Clinton failures leaves Boychuk straining at the evidence. Second, Boychuk overstates the novelty of his argument about race: It is clear from Dutton's passing references (for instance, p. 83) that the significance of race is pretty well accepted as conventional wisdom, though admittedly a conventional wisdom not much talked about. Finally, it is never clear what Boychuk thinks he is doing with respect to the prevailing cultural and institutional accounts. Is he replacing them or supplementing them? My feeling is that the latter is the more convincing, that what this book does is give us a picture of how race, coded and otherwise, was able historically to shape itself around the institutional structures that obstructed reform.

The form of Dutton's study is similar to that offered by Boychuk: a series of analytical histories of reform efforts, in this case in France and the United States. While his tone and treatment are much less self-consciously iconoclastic than those of Boychuk, this is in truth the more subversive book, precisely because it challenges one of the main assumptions in the comparative health policy literature: that the United States is indeed all that exceptional. Dutton does not deny the commonly cited features of the American health-care policy fiasco—he could hardly do so in the face of the evidence. But he argues that when the United States is put alongside France, four kinds of similarity can be observed. First, there are cultural similarities: Both are animated at their origins by common Enlightenment and revolutionary ideals. Second, there are similarities in policy outcomes: While it is true that the United States leads in cost profligacy, France is not that far behind, and the upward graph of cost inflation is similar in both systems. Third, there are critical similarities in institutional structure. Above all, both systems have placed the medical practitioner as a private entrepreneur at the heart of health-care delivery, and in so doing have contributed hugely to their common policy afflictions, especially to cost inflation. But it is the fourth common feature that most strikingly distinguishes Dutton's analysis. The combination of private practitioner power and cost inflation have driven the U.S. and the French systems in similar directions: Cost containment has produced a raft of institutional innovations in modes of health policy delivery, and a raft of innovations in the organization of the process of care (for instance, diagnosis related groups, discussed by Dutton, pp. 186–89). The model of the private medical entrepreneur has been the historical centerpiece of both American and French health care; and the ruinous consequences of that model are driving both systems in the direction of trying more closely to manage the private medical entrepreneur.

In this last respect, Dutton's analysis is iconoclastic in another way: It is highly sensitive, not just to enunciated change at the systemic level but to what is happening on the ground in the daily delivery of health care. One of the major drawbacks of the comparative political science of health care is that it is excessively focused on the history of national reform policies. Viewed in this light, the American system looks like a study in failure and stasis. But if we are prepared to look beyond the Washington Beltway, the United States looks like anything but a system that cannot change. On the contrary, the disasters of cost inflation and the collapse of the occupational health insurance system are making the United States a laboratory of policy reform. Viewed thus, as much of Dutton's study reminds us, what is striking about the United States in a comparative setting is not exceptionalism but convergence—a convergence driven by the fact of common policy pressures in formally different national health-care systems.

In all of this, Dutton is convincing, but there is one key respect in which his account is incomplete. This is “a comparative history of health care problems” that neglects—it does not quite ignore completely—one of the most important sources of convergence: the impact of globally organized medical technology industries. Medical entrepreneurs are plainly key to the delivery of care; but the means of delivery, and the increasingly costly character of that delivery, has its roots in the technology of care. Dutton has written an acute history of the people; he has neglected to write a history of the machines, and of the corporations that drive the machines.

These two books mark a considerable addition to the body of literature that tries to make sense of the American health policy experience by looking “abroad.” The Obama presidency will likely produce more rich material for the case study mill. But the body of two country case studies is now probably experiencing the law of diminishing intellectual returns. If we want to understand the United States in a comparative setting, we now need to expand into more ambitious comparisons with a wider range of countries.