In the last fifteen years of her life, Barbara Ehrenreich revisited one of the central subjects of her early work: the maddening experience of being a patient in the United States. Medical paternalism had been the focus of her early collaborations with Deidre English: Witches, Midwives, and Nurses (1972), Complaints and Disorders (1973), and For Her Own Good (1978). Decades later, after her cancer diagnosis, Ehrenreich revisited that terrain in Bright-Sided (2009) and Natural Causes (2018).
I knew all of those books — but until recently, I’d never read Ehrenreich’s earliest jeremiad against U.S. health care. The American Health Empire: Power, Profits, and Politics (1970) was written with her then-husband, John Ehrenreich, on behalf of the Health Policy Advisory Center (Health-PAC), a New York City think tank where both worked for a time. (Several chapters were co-authored by other Health-PAC staffers.)
Reading the book in 2025 offers some dismal reminders of how little has changed in the last half century. American health care, the Ehrenreichs wrote, was fragmented, unaffordable, unaccountable, inaccessible, and severely distorted by profit motives. But even as its core critique feels all too timely, The American Health Empire was the product of a very different moment.
In 1970 it was taken for granted that universal health insurance would soon be achieved, one way or another. The labor eminence Walter Reuther was promoting a model that was broadly similar to the Canadian single-payer system, while the Nixon administration was floating its own, more industry-friendly model of national insurance. In either case, the problem of uninsurance seemed sure to be solved within a few years.
The Ehrenreichs were unimpressed. The American Health Empire regarded the apparently imminent achievement of universal insurance as a “great leap sideways” that would do little to remedy the crises of access, fragmentation, overtreatment, paternalism, and racism. Universal insurance was not enough. Only a fully nationalized system such as the U.K.’s National Health Service, the Ehrenreichs held, could address the fundamental injustices of U.S. health care.
“Not merely the funding of the health system, but the system itself must be public,” they wrote. “It then becomes possible to face such questions as how such a ‘national health system‘ can be made responsive to the community and accountable to it.”
Halfway measures such as Medicare and other Great Society programs were likely to do as much harm as good, the Ehrenreichs wrote. Just look at how New York City had allowed the post-1965 flood of money from Medicare and Medicaid to degrade its postwar system of public health clinics and public hospitals.
That might sound like a paradox. Shouldn’t all that new federal money in the late 1960s have improved care, on net? The Ehrenreichs’ critique ran as follows: The new federal programs reimbursed far more generously for inpatient treatment than for any other setting, and this created incentives that favored huge hospital centers at the expense of neighborhood clinics and primary care. Much of the money was vacuumed up by rapidly rising physician salaries and by vendors of hospital equipment; some of it flowed into Columbia University’s real estate empire. Health care inflation spiked severely in 1968 and 1969.
In sum, it was no easier — if anything, harder — for working-class New Yorkers to access and afford their care in 1970 than it had been a decade earlier. “The city has less to offer,” the Ehrenreichs wrote, “to fewer people and at greater cost, than at any other time since the Depression.”
All of this was unfolding alongside the civil rights revolution. Patients and radical clinicians in New York were fighting not only for access to affordable care, but also for dignity and respect. The American Health Empire includes vivid portraits of several strains of New York activism in 1969: Mental health workers occupied and took control of a clinic in the South Bronx. A union/community alliance demanded changes at a municipal clinic on the Lower East Side, calling for investments in “diseases whose victims usually never arrived at the health center — diseases like narcotics addiction and lead poisoning.” Med students at Columbia gave patients in their own waiting rooms leaflets about the Columbia-Presbyterian system’s racist neglect of the Harlem community.
With benefit of hindsight, we can say that the Ehrenreichs were much too hopeful about what those neighborhood actions might add up to. The book contains several hand-wavy passages implying that an unstoppable movement for fully socialized health care must be just around the corner. (“The chances are that both the movement and its program will grow explosively in the next few years.”) But even if their interpretations were too expansive, it’s still bracing to read the Ehrenreichs’ accounts of patients and clinicians taking risks together to will into existence a health system that would respect human dignity.
One curious thing about The American Health Empire as an artifact is that it’s highly New York-centered (no shame in that — it was the product of a city-based think tank), and yet packaged as an indictment of U.S. health care writ large. Maybe some editor at Random House decided the book would sell better if it were framed as an Unsafe at Any Speed-style national expose. Most of the book’s attacks on paternalism, overtreatment, and general indignity did (and still do) apply to the entire country. But in at least one respect, New York was crucially different from almost everywhere else in the United States. Only New York and a handful of other cities had strong networks of public clinics and public hospitals in 1965. In the vast majority of the U.S., the arrival of Medicare and Medicaid did indeed profoundly expand low-income people’s access to health services. In that respect — especially given how little further reform there’s been in the last half-century — the book’s relentless critiques of federal programs sometimes feel off-key.
From the standpoint of 2025 — with 7.9 percent of the U.S. population still uninsured; with another 7.5 million people now facing the loss of Medicaid under the Trump budget; and with the ACA markets under severe strain — the policy climate of 1970, when universal insurance briefly seemed inevitable, might sound a little like paradise.
It wasn’t. The Ehrenreichs may have underappreciated the importance of securing universal insurance, but The American Health Empire includes many reminders of why the U.S. health system will still require profound change even after everyone is insured. If you’re tired of well-intentioned seminars couched in the tepid language of “health disparities,” the root-and-branch radicalism of this fifty-five-year-old book might be the tonic you need.
“No one is interested in reshufflings and repackagings of the same old fragments,” the Ehrenreichs wrote. “No one is interested in renovating a building which ought to be condemned. . . . When the priorities of the health system have been reversed, then it will make sense to discuss the niceties of hospital planning, or clinic administration, or group practice design.”
