With the defeat of national health reform, many liberals have looked to the states as the source of health policy innovation. At the same time, many in the new Republican majority and several governors also support increased state control. In contrast, Michael S. Sparer convincingly argues that states by themselves can neither satisfy the liberal hope for universal coverage nor the conservative hope for cost containment. He also points to two critical drawbacks to a state-dominated health care system: the variation in coverage among states and the intergovernmental tension that would inevitably accompany such a change.

Supporting his arguments, Sparer analyzes the contradictions in operations and policies between the New York and California Medicaid programs. For instance, why does New York spend an average of $7,286 on its Medicaid beneficiaries and California an average of $2,801? The answer, the author suggests, is rooted in bureaucratic politics. California officials enjoy significant bureaucratic autonomy, while the system in New York is fragmented, decentralized, and interest-group dominated. The book supports this conclusion by exploring nursing home and home care policy, hospital care policy, and managed care policy in the two states. Sparer's dissection of the consequences of state-based reform make a persuasive case for national health insurance.

After the Vietnam War, the U.S. Army considered counterinsurgency (COIN) a mistake to be avoided. Many found it surprising, then, when setbacks in recent conflicts led the same army to adopt a COIN doctrine. Scholarly debates have primarily employed existing theories of military bureaucracy or culture to explain the army’s re-embrace of COIN, but Peter Campbell advances a unique argument centering on military realism to explain the complex evolution of army doctrinal thinking from 1960 to 2008.

In five case studies of U.S. Army doctrine, Campbell pits military realism against bureaucratic and cultural perspectives in three key areas—nuclear versus conventional warfare, preferences for offense versus defense, and COIN missions—and finds that the army has been more doctrinally flexible than those perspectives would predict. He demonstrates that decision makers, while vowing in the wake of Vietnam to avoid (COIN) missions, nonetheless found themselves adapting to the geopolitical realities of fighting “low intensity” conflicts. In essence, he demonstrates that pragmatism has won out over dogmatism. At a time when American policymakers remain similarly conflicted about future defense strategies, Campbell’s work will undoubtedly shape and guide the debate.
 

This provocative, lucidly written reconstruction of utilitarianism focuses on the practical constraints involved in ethical choice: information may be inadequate, and understanding of causes and effects may be limited. Good decision making may be especially constrained if other people are closely involved in determining an outcome. Hardin demonstrates that many of these structural issues can and should be distinguished from the thornier problems of utilitarian value theory, and he is able to show what kinds of moral conclusions we can reach within the limits of reason.