Salient Facts Or Causal Keys?

Abstract

To understand the strengths and weaknesses of this thoroughly researched, comparative study requires attention to both the title and the subtitle of the book. The obvious subject matter is how the politics of national health insurance evolved historically in both nations. Here, Gerard Boychuk, director of global governance at the Balsillie School of International Affairs in Canada, covers ground others have addressed, but he brings to the topic admirable clarity and narrative skill. The subtitle—race, territory, and the roots of difference (in national health insurance politics)—is a very different matter. As I wrote candidly in a blurb prior to publication, this is a “bold revisionist” work. It “challenges” received explanations of the “divergent paths” Canada and the United States have indisputably taken over the past fifty years or more. For Boychuk, the puzzle is why others have not paid attention to obvious factors he finds causally crucial: namely, American race relations and Quebec’s special territorial place in Canada’s federalism. The book, I concluded, is a “worthy addition to the literature,” but that judgment requires additional explanation. Like others who have noted but not highlighted the differentiating factors Boychuk stresses, I find the causal centrality of these features unconvincing. Put another way, the factors are obvious, but not their causal force. It is indeed true that no one observing American politics over the past century could miss the salience of racial conflicts in that history. But a salient fact is not by itself a causal key. Imagine as a counterfactual that the South had only had a white population, with all of the other factors of agriculture, sharecropping, poverty, and class structure the same. Would national health insurance have become much more likely, say, in 1948, or 1961, when the Kennedy administration opted for a Medicare strategy? Looked at this way, the ever-present elements of racial division in those years accompanied—and contributed some to—the conservative coalition of southern Democrats and traditional Republicans that effectively killed national health insurance for decades. Equally, Quebec—although the last province to accept full Canadian Medicare in 1971—would not have transformed the program’s history if somehow its role had disappeared. The key step is to ask the “but for” question and reflect, as opposed to insisting that one or another factor has to be central. None of this is to claim that in the course of dealing with the deep ideological and interestbased conflicts over national health insurance that race and Quebec’s status played no role: at different points, the story might well have been a bit different had these factors been absent. Yet this does not substantiate the stronger claim that Boychuk wants to make. Boychuk instead insists on treating U.S. race relations and Quebec’s role in Canadian federalism as the “roots” of the different results. At best, it led him to review a number of B o o k R e v i e w s