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

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Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform. By Paul Starr. New Haven, Conn.: Yale University Press. 2011. 309 pp. $28.50.

Many readers familiar with Paul Starr's highly acclaimed book, The Social Transformation of American Medicine, published nearly three decades ago and recognized today as the definitive history of the medical profession's rise to prominence in the United States, have long wished for a sequel that would carry the story forward to the present day. Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform is not that sequel, but it unquestionably is a worthy companion to Starr's earlier work.

This aptly titled book recounts the century-long struggle over health reform in the U.S., beginning with the Progressive era of 1915-1919 and concluding with the Patient Protection and Affordable Care Act (ACA) of 2010. Curiously, the inspiration for the book's title is not revealed until the final chapter when Starr credits Arthur Schlesinger, Jr., with having noted "that politics in a democracy (transcends) the struggle for power or the manipulation of image" and "is above all about the search for remedy." Starr hastens to add that the search for remedy to a social problem inevitably triggers reaction, especially in a deeply divided political environment. He calls the American struggle over health care "peculiar" because of the unusual lines on which it has been fought and because the problems are not restricted to the least powerful members of society. For example, he points out that special interests have not always been aligned only on one side of the debate, and that much of the bias against change often comes from "members of the protected public," such as Medicare beneficiaries. He also argues that many middle-class Americans, not just the poor, suffer the misfortune of becoming sick while being uninsured. Such peculiarities are unique to our system, and they continue to shape both our political debate and our current reform efforts.

The book is divided into three parts. In Part I, Starr traces health care reform from its origins as a search for universal health insurance in the Progressive era, followed by the failure to enact national health insurance (along with Social Security) during the Great Depression and New Deal years, to its evolution as a quest for comprehensive system reform in the 1970s and 1980s. He describes the "policy trap" that ensnared the U.S. following World War II, when American Medical Association opposition to national health insurance defeated President Truman's proposal even as Congress enacted legislation that led to unprecedented hospital construction and service expansion (exactly the reverse of Western democracies' establishment of universal insurance programs before embarking on campaigns of system infrastructure development). Once private employer-based insurance had become the dominant form of coverage for many Americans, Starr argues that the U.S. found itself with a "deeply dysfunctional system that the country could not readily bring itself to change." Although the creation of the Medicare and Medicaid programs in 1965 was a limited victory for social insurance, it also added to the complexity and fragmentation of the health care system, further hampering reform efforts. Starr highlights the dramatic shift in reform efforts from a focus on coverage to a focus on costs as health care spending grew at historic rates following the lifting of wage and price controls in 1974. …


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