Remedy and Reaction: The Peculiar American Struggle over Health Care Reform [Hardcover]

Paul Starr (Author)

Book Description

Publication Date: October 25, 2011 | ISBN-10: 0300171099 | ISBN-13: 978-0300171099 | Edition: 1

In no other country has health care served as such a volatile flashpoint of ideological conflict. America has endured a century of rancorous debate on health insurance, and despite the passage of legislation in 2010, the battle is not yet over. This book is a history of how and why the United States became so stubbornly different in health care, presented by an expert with unsurpassed knowledge of the issues.

Tracing health-care reform from its beginnings to its current uncertain prospects, Paul Starr argues that the United States ensnared itself in a trap through policies that satisfied enough of the public and so enriched the health-care industry as to make the system difficult to change.

He reveals the inside story of the rise and fall of the Clinton health plan in the early 1990s—and of the Gingrich counterrevolution that followed. And he explains the curious tale of how Mitt Romney’s reforms in Massachusetts became a model for Democrats and then follows both the passage of those reforms under Obama and the explosive reaction they elicited from conservatives. Writing concisely and with an even hand, the author offers exactly what is needed as the debate continues—a penetrating account of how health care became such treacherous terrain in American politics.

Editorial Reviews

Review

"[A] clear, comprehensive, and compelling chronicle of the health care debate....Starr is at the top of his game."—Glenn Altschuler, Huffington Post (Glenn C. Altschuler Huffington Post )

"[Starr's] unsentimental perspective serves him well in this outstanding volume."—Harold Pollack, Washington Monthly

(Harold Pollack Washington Monthly )

Winner of the 2011 American Publishers Awards and Scholarly Excellence (PROSE) in the Government and Politics category, as given by the Association of American Publishers

(PROSE Award in Government and Politics Association of American Publishers 20120202)

"Remarkable. . . . There couldn't be a more astute insider to the politics of reform than Starr. . . . Starr's history of America's battle over whether health care should be a right is an exacting look at politics and policies—and a challenge to Americans to overcome their fear and distrust in order to protect the sick and vulnerable."—Publishers Weekly, Starred Review

(Publishers Weekly )

"First, [Starr] objectively draws together the threads of myriad voices and special interests in the centurylong American health-care debate and weaves them into a wholly comprehensible pattern. ...Second, Starr cogently explains the highlights of the recently passed and highly controversial Affordable Care Act...In sum, this self-admitted universal-health-care advocate and seasoned realist leaves readers questioning, as he does, whether Americans can 'summon the elementary decency toward the sick that characterizes other democracies.'" —Donna Chavez, Booklist (starred review)

(Donna Chavez Booklist )

“The best summary and political analysis of health care reform I’ve read....Starr nails every nuance while taking the analysis one level deeper than any other treatment I’ve read.”—Austin Frakt, The Incidental Economist (Austin Frakt The Incidental Economist )

“Paul Starr has written a fascinating chronicle of America’s century-long journey to health reform that is, at once, erudite history, vivid journalism, and authoritative guide to a debate that will continue for decades.”—Henry J. Aaron, co-author of Using Taxes to Reform Health Care

(Henry Aaron 20110602)

"Three decades ago Paul Starr wrote the definitive history of American medicine.  Remedy and Reaction now offers the definitive analysis of American health care reform—its history, nature, and continuing vulnerability."—Timothy Jost, co-editor, Transforming American Medicine:  A Twenty Year Retrospective

 

(Timothy Jost 20110606)

"Remedy and Reaction is the story of health care in America, told by the man who knows it best. Whether you're a serious scholar or just a serious citizen, you should read this."—Jonathan Cohn, senior editor, The New Republic

(Jonathan Cohn 20110614)

"Here’s the book we’ve been waiting for—a lucid history of America’s struggle over healthcare reform, blending the political, economic, and social pressures that have brought us to where we are, and suggesting where we’re headed. With great insight and impeccable writing, Paul Starr explains why that struggle has been particularly bitter and partisan in the United States, why the resulting compromises have left so many people unsatisfied, and why the underlying problems continue to evade us. Brilliant and important."—Robert B. Reich, Chancellor's Professor of Public Policy, Goldman School of Public Policy, University of California, Berkeley

(Robert B. Reich 20110617)

"Paul Starr, who gave us a magisterial account of the history of American medicine, now has given us the definitive account of the history of the struggle to enact health reform in America. Starr has done more than just study reform—he was a player in efforts to achieve it. Remedy and Reaction is in some ways thus an insider's history, which only enriches the experience of the reader. This book is a lively read, but has depth and insight. From its account of the early experiences in the twentieth century with reform, up through the disappointments in our livetimes to achieve any comprehensive change, through the enactment of the Affordable Care Act and the story of its uncertain future, Remedy and Reaction is the definitive account of the history of health reform in America." —Norman Ornstein, co-author of The Broken Branch: How Congress Is Failing America and How to Get it Back on Track

(Norman Ornstein 20110627)

"Few books as important as this one is are as clearly and compellingly written.  Remedy and Reaction is a brilliant analysis of the political conflicts and compromises that led to the passage of the Affordable Care Act, and a fitting sequel to Paul Starr's masterful book, The Social Transformation of American Medicine. The final page came much too soon."—Shannon Brownlee, author of Overtreated: Why Too Much Medicine is Making Us Sicker and Poorer

(Shannon Brownlee 20110628)

"[D]elivers an insightful political analysis."—Kristen Greencher, The Charlotte Observer

(Kristen Greencher The Charlotte Observer )

"As a work of policy history Remedy and Reaction excels…. [Starr] chronicles just how difficult a struggle it has been to make the U.S. healthcare system more equitable and efficient and how far we still have to go."—Jonathan Oberlander, Science

(Science )

“ [A] remarkable chronicle of the hundred-year effort to legislate universal health insurance in the United States…. Nobody with a sense of history—that is, nobody who reads Starr’s book—could doubt how sensible and brave was the president’s effort to drive the Patient Protection and Affordable Care Act of 2010 through Congress.” —Bernard Avishai, The Nation

(Bernard Avishai The Nation )

"[An] interesting and engaging account of the many attempts made over the past century to reform care in this country. As daunting, even wonkish, as this may sound, Starr does an excellent job of explaining the different proposals and identifying the reasons why some succeeded where others failed so spectacularly."—Dennis Rosen, Boston Globe

(Dennis Rosen Boston Globe )

"[A] useful and lucid history of American health reform . . . Anyone seeking to understand how difficult it will be to implement President Barack Obama's health care reforms will be enlightened by Starr's readable and engrossing narrative. Highly recommended."—Jeff Goldsmith, Health Affairs

(Jeff Goldsmith Health Affairs )

"[C]oncise and beautifully written."—Michael Gusmano, Commonweal

(Michael Gusmano Commonweal )

"None of the numerous other histories of US health care policy develops these themes in such an illuminating fashion. . . . [an] excellent, cogently argued work."—Samuel Y. Sessions, Journal of the American Medical Association

(Samuel Y. Sessions Journal of the American Medical Association )

“Excellent, cogently argued.”—Journal of the American Medical Association

(Journal of the American Medical Association )

“Engrossing.”—HealthAffairs

(Health Affairs )

From the Author

What do you most want people to understand from reading this book?
 I hope the book illuminates how an issue that is more or less settled in every other democracy became a seemingly intractable political problem in the United States.
It did not have to turn out this way. The legislation adopted in 2010 has its roots in moderate Republican proposals. But America’s polarized politics make it difficult to see the reforms clearly and put them in historical perspective. I hope the book helps to provide that understanding.

What’s the relationship of Remedy and Reaction to your 1984 book, The Social Transformation of American Medicine?
 In some ways it’s a sequel, but each of its three parts has a somewhat different foundation.  Part One, about how health-care reform and the health-care system took shape during the twentieth century, presents the same kind of social and historical analysis as Social Transformation did.
But Part Two, which deals with the parallel stories of the Clinton health plan and Republican health reforms in the Gingrich and Bush years, also reflects my observations inside the Clinton White House. That’s a kind of experience not usually available to historians.
Finally, Part Three, about the battle over health-care reform under Obama, combines journalism and historical analysis because it draws on interviews with participants, many of whom I know from my prior time in Washington.

Why did Obama succeed where Clinton failed?
 Between 1993 and 2009, the biggest change was the emergence of a consensus about the basic elements of legislation among reformers, major interest groups, and leading Democrats in Congress. The reforms adopted in Massachusetts in 2006 as a result of Mitt Romney’s leadership were critical in shaping that consensus.  Obama accepted that approach; he didn’t originate it. Romney probably deserves more credit for the basic architecture of the national reforms, and I hope one day he proudly accepts that credit.

Didn’t Obama’s leadership matter?
If Obama hadn’t decided to make health-care reform a priority as president, it would never have passed.  Why did he take it on? His earlier history didn’t indicate a deep commitment to health-care reform. I think the 2008 presidential campaign was crucial because of the pressure from the party base to confront the issue, plus an accident of history: he ran into Hillary Clinton on the way to the nomination, and debating her forced him to master health policy. Perhaps most important, the support for reform from key stakeholder groups and members of Congress changed the political calculus on health care. That’s what made it a better bet than climate legislation.

See all Editorial Reviews

Product Details

• Hardcover: 336 pages
• Publisher: Yale University Press; 1 edition (October 25, 2011)
• Language: English
• ISBN-10: 0300171099
• ISBN-13: 978-0300171099
• Product Dimensions: 9.5 x 6.5 x 1.1 inches
• Shipping Weight: 1.2 pounds
• Average Customer Review: 4.4 out of 5 stars  See all reviews (9 customer reviews)
• Amazon Best Sellers Rank: #56,884 in Books (See Top 100 in Books)
  • #49 in Books > Politics & Social Sciences > Politics & Government > Public Affairs & Policy > Social Policy
  • #49 in Books > Medical Books > Administration & Medicine Economics > Health Policy
  • #53 in Books > Medical Books > Administration & Medicine Economics > Public Health > Epidemiology

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Most Helpful Customer Reviews

24 of 25 people found the following review helpful

5.0 out of 5 stars Readable discussion of health care reform November 3, 2011

By bjcefola

Format:Hardcover

This is an extraordinarily readable discussion of health care reform. The book is worth getting for the first chapter alone, which summarizes reform efforts from the progressive era through Carter with enough detail to articulate why programs like Medicare succeeded versus the many others that failed.

Starr then devotes chapter length treatments to the Clinton and Obama plans, describing how the Clinton plan got sandbagged and how Democrats in 2009 struggled to avoid the same fate.

Highly recommended!

31 of 34 people found the following review helpful

5.0 out of 5 stars Excellent - October 23, 2011

By Loyd E. Eskildson HALL OF FAME

Format:Hardcover

The U.S. spends far more on health care than others - 17.6% of GDP, compared to an average of about 9% in other economically advanced nations. Meanwhile, as of 2010, about 50 million Americans are without health insurance at any time, our outcomes are, at best, only comparable, and variation in disease rates do not explain the cost differences either. Higher prices, however, do. Paul Starr's 'Remedy and Reaction' provides excellent insight into how this has occurred. Briefly, during the first half of the 20th century the U.S. diverged from the more common path taken by western democracies and failed to establish a general system to finance health care. Instead, it ensnared itself in what Starr calls 'a policy trap,' devising an increasingly costly and complicated system that satisfied enough of the public (veterans - a separate system established after WWI; employer provided - encouraged by tax benefits and its offering a way around WWII wage/price controls; Medicare - 1965; Medicaid - 1965) and so enriched the industry as to make change very difficult now that it consumes nearly one-fifth the American economy. When the major European countries created their national insurance systems between the 1880s and early 1900s, health care was a small proportion of their economies, about 3%, and thus much more easily maneuvered.

Now, not only are providers and insurers likely to provide strong resistance to change, the public is as well. Some because they view their existing coverage as 'earned' and resent others receiving similar status, others see their freedom of choice being limited, while fear of benefit reductions and/or growth in government spending motivate still others. Of course, providers and insurers have also learned to take advantage of these mostly highly organized and vocal groups for their own benefit. The result - proposals for change to-date have been forced to follow far more complicated paths than those of an ideal solution, thereby making acceptance even more difficult and expensive. Overhead expenditures for private insurance in the U.S. average 30% - a single, government plan, or even standardized rules for multiple insurance fund sources offer significant savings (eg. 3% overhead expenditures for Medicare) - yet, partly because health care expenditures are generally shared between employer, employee, and government, the pain has not yet reached the point of forcing major restructuring - despite family health premiums rising 87% from 2000 to 2006 while real median household income declined 3%, and general recognition that control of our deficit and unfunded liabilities is impossible without throttling rising health care costs. Thus, conservative politicians (Republicans) are able to not only block reform efforts with impunity, but seemingly are rewarded for doing so in subsequent elections. (Starr notes that ideological obstacles have strengthened - by 2009, every Republican Senator had a voting record to the right of their most conservative Democrat colleagues.)

Complications in drafting any legislation in this area include who to cover (eg. illegal immigrants), what to cover (eg. abortion), how to finance the system (federal, state, individual, employer), mandating coverage (essential for insurance company acceptance and financial soundness, but guaranteed to generate major legal challenges), and how long to take phasing in the new system (faster --> higher immediate costs, slower --> greater opportunity for opponents to create obstacles). Vocal and dishonest conservative mouthpieces are another major problem - eg. false claims of mandatory counseling every five years on end-of-life planning, 'death panels,' 'government takeover; scripted disruptions of Town Hall meeting to discuss the topic).

The result - the future of 'ObamaCare' is uncertain, the legislation is overly complex (2,000+ pages), and its cost-controls are weak (adherence to efficacy research findings cannot be mandated).

3 of 3 people found the following review helpful

5.0 out of 5 stars So Good It Changed My Mind! December 1, 2012

By Anne Mills

Format:Hardcover|Amazon Verified Purchase

An excellent and very informative history of government efforts to reform health care in the U.S., leading up to a brilliant analysis of the politics that shaped and (just barely) achieved the passage of the Affordable Care Act (aka Obamacare) in 2010. The second half of the book is fascinating, a political thriller that (like Spielberg's "Lincoln") lays bare the grubby political maneuvering that allowed the achievement of a morally desirable end.

As a progressive Democrat, I had though that Obamacare did too little, and gave away too much to health-care interests. This book made it clear to me that, in 2010, the sort of health care reform that progressives wanted was not politically possible. It also made it clear to me that Obamacare was a major achievement that will have increasingly positive effects over time -- an achievement that now seems likely to remain in place.

Given the enormous amount that has been written on current U.S. health policy, it is hard to know where to turn for analysis. Paul Starr's resume suggests that this book is a good place to start. He is an eminent expert in the field of public policy. He is a professor of sociology and public affairs at the Woodrow Wilson School at Princeton, co-founded the liberal magazine "The American Prospect", and has written many books on public policy, including the Pulitzer winning "The Social Transformation of American Medicine". Despite his academic background, however, he writes in a real world political framework, and has the experience to back it up -- he was a senior advisor to President Clinton during the 1993 attempt to reform healthcare. Clearly, he has a liberal back- ground, but his analysis focuses on facts.

The first half of the book surveys efforts to reform U.S. health care over the past hundred years. In so doing, it shows why the U.S. system has evolved so differently from that in most other wealthy democracies, where access to health care has long been treated as a basic right. There is a lot more to this difference than the "greedy health care interests" that progressives like me view as the problem. The interests are certainly greedy, but then so are most people and institutions, in most countries. In part, the U.S. situation reflects an individualistic national ethos, and in part a series of historical accidents. Starr's focus is not, however, on American exceptionalism, or on randomness.

Rather, his point is that efforts to reform health care in the US contributed to the development of a system that is extraordinarily hard to reform. Two of these were critical. First, in 1953, the IRS ruled that employer contributions to group health insurance policies were not taxable. That made health benefits an attractive way for companies to compete for labor, and employer-based insurance became the dominant form of health care provision in the U.S. This meant that a large portion of the population was reasonably well insured against medical costs -- they formed a "protected population" that did not face any personal need for improved access to medical care. Second, in 1965, President Johnson pushed through Medicare, and Medicaid. Like employer-based insurance, Medicare put many millions of people into a protected category.

These two events created a big protected population, creating what Starr calls a "policy trap". That is, as he describes it, "an increasingly costly and complicated system that has satisfied enough of the public and so enriched the health-care industry as to make change extraordinarily difficult." The first half of the book shows how we reached that policy trap.

The last section of the book, happily, is not nearly so relevant as it was when the book was published in October of 2011. That is because it dealt with the threats to Obamacare from the then-pending Supreme Court decision, and from the 2012 election. Those removed the threat of judicial overthrow or a post-election repeal. For this, many people should give thanks.

The second half shows how the Obama Administration succeeded in implementing a truly major reform of health care despite this trap -- and by the skin of its teeth. This half is much more fun that the first half, because most of the players are still very much with us, and because the events are just fading out of the headlines. Starr writes it like a political thriller, with lots of who did what to -- and for -- whom. This discussion, however, benefits enormously from the less entertaining first half of the book, which makes it clear why Obamacare was so hard to pass, and why it had to be more limited than many progressives would have liked.

In a penultimate section, Starr analyses the Affordable Care Act, treating it as a major but limited effort. Its key effects are to sharply reduce the percentage of the U.S. population that is uninsured, from 17% to an estimated 6%, and to improve protection for the middle class. But it does this mostly through changes in insurance, leaving the organization of medical care largely unchanged. It includes efforts to slow the growth of spending on health care, but does not assure that end.
Despite that, after reading Mr. Starr's book, I feel much more positive about Obamacare than I did. It may not be perfect, but -- given the obstacles to reform -- it is important and impressive.

For those who are interested in a more polished review, check out the NYT review at [...]