The Health Care Policy Trap: Lessons for Canada from Health Care Reform in the United States
Marchildon, Gregory P., Inroads: A Journal of Opinion
Paul Starr, Remedy and Reaction: The Peculiar American Struggle over Health Care Reform. New Haven and London: Yale University Press, 2011. 324 pages.
Paul Starr is a professor of sociology and public affairs at Princeton University. In 1982, he published The Social Transformation of American Medicine, a masterful two-century history of the American medical profession and the health care system. The book went on to win a Pulitzer Prize. In 1990, along with Robert Kuttner, he founded The American Prospect, a magazine that has attempted to fight the powerful neoconservative tide in the United States by presenting proactive and workable "liberal" policy alternatives. Three years later, Start left the ivory tower for a short time to become a senior adviser to Bill and Hillary Clinton in their ill-fated health reform effort.
Remedy and Reaction, Starr's most recent book, is the best analysis so far of the tortuous evolution of health reform in the United States. He focuses almost all his attention on the last two decades, from the failed Clinton reform in the 1990s to the 2008 nomination and election debates that led to Barack Obama's Affordable Care Act of 2010. From the beginning, Starr has maintained that medically necessary health care is a critical aspect of what he calls "human development and security" and should be a right of citizenship. Pointing out the "peculiarity" of the American case, he argues that the inability to accept health care as a right and achieve universality makes the United States an anomaly among wealthier industrialized countries.
More significantly, he concludes that his country is also internally inconsistent. Strangely enough, Americans long ago accepted that access to education was a right. They also agreed that providing the elderly and disabled with economic security was a universal right. Yet when it comes to basic health care, the debate continues to be polarized because of the number of Americans who continue to see access to medically necessary care as something that should be earned privately. Figuring out why citizens who assume that there is nothing wrong with treating education and old age pension security as a collective right reject the same principle for health care is the central question of this book.
Indeed, until the Clinton effort in the 1990s, there was no real attempt to achieve universality: "Franklin Roosevelt put off proposing national health insurance because he wasn't willing to take the political risk it entailed; Harry Truman endorsed the principle but never submitted legislation, knowing it was certain to be defeated." Lyndon Johnson, accepting private employment insurance as the foundation of the American health system, patched that system with two targeted programs. Seeking to fill in two of its largest cracks, Johnson sponsored Medicare and Medicaid in 1965.
A federal social security program, Medicare provided health insurance to Americans aged 65 and older who made a minimal contribution through social security during their working lives. A combined federal-state program ensuring access to the most basic health services, Medicaid was for the very poor--those without jobs or the occasional low-paid job without health benefits. The unintended consequence of these programs was to create a "policy trap"--Staff's phrase--at both state and federal levels that would make it almost impossible for health care to become a universal right in any individual state, much less the country as a whole.
First of all, both programs reinforced the centrality of employment-based insurance with its opaque funding divided between employers and employees, and related tax expenditure subsidies provided through governments. The end result was a lack of transparency concerning the actual value for money of private health insurance as well as the extent to which public revenues are used to subsidize private health insurance, often for Americans who least need government subsidies. …