- Hardcover: 336 pages
- Publisher: Yale University Press; 1 edition (October 25, 2011)
- Language: English
- ISBN-10: 0300171099
- ISBN-13: 978-0300171099
- Product Dimensions: 6.8 x 1.2 x 10 inches
- Shipping Weight: 1.2 pounds
- Average Customer Review: 24 customer reviews
- Amazon Best Sellers Rank: #285,179 in Books (See Top 100 in Books)
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Remedy and Reaction: The Peculiar American Struggle over Health Care Reform 1st Edition
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"[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)
“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, 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 2011-06-27)
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.
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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 [...]
This current work is a rigorous, detailed examination of the history of attempts to enlist the US society at large in the health care of its citizens, and includes a thoughtful explanation of how these efforts have been repeatedly derailed.
The book is to be valued especially for its account of the evolution of the Affordable Care Act. For example, I had forgotten -- or perhaps didn't pay attention in the passing of events -- such turning points as when candidate Obama changed his mind on the issue of the individual mandate.
Some may find their eyes glazing over with the recapping of events that transpired in Congress during these years, they are described in such detail. This is more than compensated for by the incisive and powerful summaries Starr provides in the introduction and in the concluding pages of the book.
Most recent customer reviews
He explains why they failed and describes some of the benefits included.Read more