Abstract
“Do we have an obligation to provide health care for our citizens?” Paul Starr opens his outstanding Remedy and Reaction with this question and follows up by asking another more vexing one: why is the U.S. healthcare system so stubbornly unique among capitalist democracies? It is a well-known and embarrassing fact that the United States has the most expensive healthcare system in the world and yet has the highest number of uninsured citizens of any Western democracy. But the solution to the problem has always eluded us. The answers to Starr’s questions vary widely across the political spectrum, exposing deep divides between and within the major political parties, and reveal how a combination of social forces prevents the United States from guaranteeing what people in many other democracies view as a fundamental right.
Starr’s argument is that the United States missed a chance to set up a general system for financing healthcare in the first half of the twentieth century, and when the government finally sought to do so, the nation was caught in what he calls a policy trap, in which enough of the public and healthcare industry leaders were satisfied with the complicated and costly system that changing it became nearly impossible.
He addresses the three factors usually indicted for producing the healthcare crisis in the United States: “special interests,” national values, and “the daunting complexity of the problems of health care and health policy” (p. 6). And while Starr agrees that there is some truth within each of these explanations, he challenges the claim that any one of them alone is responsible for the quagmire that is our healthcare system.
Of the three explanations, the argument that “special interests” have prevented major healthcare reform carries particular weight with many observers. After all, as Starr demonstrates throughout the book, the American Medical Association and other key stakeholders actively opposed anything resembling a national healthcare system virtually anytime the idea emerged in U.S. politics. But that explanation is too tidy because there have been moments when healthcare industry leaders have supported expanded coverage proposals that they viewed as better than less appealing alternatives such as “single payer.” The “special interest” explanation really falls short when we discover that the public itself is split over reform because unionized workers, veterans, disabled persons, and the elderly can access Medicare, while segments of low-income populations can also qualify for Medicaid. These millions of Americans may not have the best healthcare, but they often see themselves as “reasonably well-protected” and fear losing their coverage or benefits under any major reform, particularly since they feel they have earned their way into such programs while other groups are seen as less worthy. This is the most disturbing and revealing aspect of the healthcare crisis in this country, and—although Starr does not draw the link—it has strong echoes of the kind of divisive sentiment that has shaped other public welfare programs. It calls to mind the racist exclusions of agricultural workers and domestic servants from New Deal programs such as the Social Security Act and the retraction of core elements of social programs during the War on Poverty as a result of anxieties and frustrations among white Americans who believed those policies should primarily benefit them. And recall the invidious distinction that citizens, the government, and the media have often made between the “poor” and the “deserving poor,” from the early twentieth century through the “welfare queen” debates of the 1980s to the contemporary struggle over whether and how to maintain the food stamp program intact. So while the U.S. healthcare system is unique in many ways, this history and ongoing thread of fear and loathing is what reveals how healthcare is indeed very much like many other public policies, because it speaks to continuing concern over who should be included in such programs and who can be excluded.
With great detail and authority that no other healthcare scholar can summon, Starr takes us through several eras and presidential administrations during which healthcare reforms were proposed, flirted with, taken seriously, and yet fell short of the mark again and again. We see this frustrating turn of events in the FDR, Truman, Nixon, and Clinton administrations, and it is stunning to see how close we came to success on a number of occasions. Given this repeated failure, how did the Obama Administration succeed in passing the Affordable Care Act? Starr’s analysis is persuasive and underscores that the ACA’s success may have been due in part to the fact that the legislation is quite limited. He writes, “the law does not substantially alter how medical care is organized, and it may not change the long-term trajectory of health spending” (p. 239) because it ultimately only sought to make healthcare and health insurance “affordable,” not free. Moreover, the ACA is a market-based program that embodies a subtle rebuke of the idea that healthcare is a right—instead it is repackaged as a “responsibility.”
The subtitle of the book contains the phrase “the peculiar American struggle,” reminding the reader of what could have been expanded in this powerful work: greater consideration of the ways that social divides between racial and class groups have contributed to the continued rejection of a national healthcare system in the United States. As indicated earlier, we see these divides playing out in other social welfare programs, and it seems that this is the terrain on which one will find that healthcare may not be all that unique when compared to other American institutions. Indeed, when one considers the stark inequities in other areas of American life—for example, in education and the criminal justice system, compounded by vast health disparities and growing gaps in wealth, income, and exposure to environmental hazards—we see a general trend of continued and expanding inequality between social classes and between people of color and whites. And, as with healthcare, in those arenas we see a familiar pattern of rising costs combined with dismal outcomes. So while the dissimilarities between the U.S. healthcare system and those of other Western democracies are significant, an equally telling comparison might be to examine that system against other domestic social programs and institutions. That comparison would likely yield few surprises and a great deal of symmetry, prompting one to ask one of the biggest questions of all: to what extent are we committed to the full inclusion and basic needs of our nation’s citizens—including and well beyond the question of healthcare?
In addition to marshaling a trove of data from the historical record, Starr brings his rich insider perspective to the narrative, drawing from his experience as a Senior Advisor on health policy in the Clinton White House. This is first-rate scholarship and will be a must-read for anyone seeking an authoritative analysis of the U.S. healthcare system.