Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform Hardcover – 25 Oct 2011
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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.
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).
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.