Breakthrough or Impasse?

In the century prior to the passage of the Patient Protection and Affordable Care Act (PPACA) in 2010, the United States had repeatedly tried—and failed—to adopt comprehensive health-care reform. Although the new law falls short of offering universal coverage, the PPACA represents a remarkable political achievement long viewed by many as impossible. And yet its future is in jeopardy. The Supreme Court has agreed to hear a challenge to the law, and the outcome of that review, expected in June 2012, is uncertain. And since the most controversial provisions—such as expanding the Medicaid program and requiring individuals to purchase health insurance while offering subsidies to people with lower incomes—are not scheduled to be implemented until 2014, the 2012 election could also result in a repeal of the law or an elimination of its funding. Are we looking at a breakthrough, or a continued impasse? Why are we so confused when it comes to changing our health-care system?

In Remedy and Reaction, Princeton sociologist Paul Starr argues that the special nature of our political institutions and culture has combined with a lack of effective leadership and a legacy of divisive policy decisions to shape what he calls the “peculiar American struggle” with health-care reform. In Starr’s view, these factors account not only for the longstanding difficulty of adopting reform, but also for the features of the PPACA that limit its reach and threaten its implementation. Remedy and Reaction is a concise and beautifully written account of health-reform politics in the United States since the Progressive Era, with a particular emphasis on the period since 1991—a period that includes the spectacular collapse of President Bill Clinton’s health-reform plan and the unsteady and still-doubtful triumph of the PPACA.

The first section of the book offers a summary of health-reform efforts up to the early 1970s, drawing liberally from Starr’s Pulitzer Prize–winning 1982 book, The Social Transformation of American Medicine. The new work’s main contribution lies in its discussion of the Clinton health-reform plan and the influence this effort had on the debate in 2009–2010. As one of Clinton’s health-care advisers, Starr is eager to counter misunderstandings about how the plan was developed, and he persuasively dismisses such canards as the notion that Clinton’s Health Security Act was the brainchild of the First Lady, or that its details were crafted by a task force of over five hundred. What really sank the Clinton plan were the familiar old obstacles: institutional barriers (particularly the need for sixty votes to overcome a filibuster in the Senate), poor strategy by the administration, bungling by divided congressional Democrats, and a well-organized opposition wielding a successful strategy of fear-mongering.

Starr shows how reform was hindered by a political system in which fragmented power makes it easier for powerful interest groups to veto change—and by the divisive legacies of previous policy decisions. The move to focus on health insurance for older Americans as a first step toward national health insurance, for example, effectively split the public, allowing opponents of government expansion to argue that the new programs would harm people who currently enjoy satisfactory health insurance coverage. Starr sees this as an ongoing concern for the PPACA, which has particularly low levels of support among Medicare beneficiaries—a weakness Republicans hope to use to their advantage in 2012.

Ironically, one factor that undermined political support for the Clinton plan was the inclusion of cost-control measures far more stringent than anything later contained in the PPACA; these measures, Starr argues, reflected Clinton’s commitment to deficit reduction following the Reagan-Bush years, and set him at odds with some congressional Democrats. By comparison, in 2009, congressional Democrats were more unified, fearing that the defeat of another health-care reform plan would represent a political victory for the Republicans. Starr argues convincingly that Obama’s success was aided by the memories of Clinton’s failure, and by an increasing polarization of American politics between 1994 and 2008. While the Republican majority in the 1990s House, led by Speaker Newt Gingrich, had failed in their plan to privatize Medicare, by 2003 the Bush administration had managed to expand the use of private-sector plans in the program, sugar-coating the move by coupling it with a new, expensive, and popular drug benefit for beneficiaries. Democrats and moderate Republicans, meanwhile, focused on incremental expansion of health-care coverage. But no one was doing anything to keep the number of uninsured and underinsured from increasing, or to address the skyrocketing costs of health care.

By the time Obama was elected president in 2008, many of the interest groups that opposed health-care reform in the 1990s had grown more receptive. Starr shows how, as the price of care continued to increase and the number of uninsured grew, the insurance and pharmaceutical industries began to see the advantages of public financing. Obama and the leadership in Congress still had to overcome opposition within their own party, as well as from powerful interest groups with a financial stake in the system, and such cooperation came with a steep price. The pharmaceutical industry would not accept federal government negotiation of prices in the Medicare program. The insurance industry was willing to accept aggressive federal regulation, but only if the law included an individual mandate. Conservative Democrats would not support a public insurance alternative that would compete with private plans, and prolife Democrats demanded assurances that public money would not fund abortion. Remedy and Reaction shows that when it comes to changing even a blatantly overburdened and inefficient system, nothing is easy.

The struggle described by Starr illustrates recent changes in the American political landscape. Some will be surprised to learn that the most controversial aspect of the new law, the individual mandate, was actually a Republican idea, introduced by the moderate senator from Rhode Island, John Chaffee, in the early 1990s—and was later adopted by Massachusetts Governor Mitt Romney. Although some of Romney’s conservative advisers viewed an individual mandate as inconsistent with Republican principles, Romney argued that its requirement of personal responsibility made it the “ultimate conservative idea.” Indeed, as late as early 2009, some of the more moderate Republicans in Congress signaled a willingness to accept an individual mandate—until, in the face of growing partisanship over Obama and his plan, they caved in and joined the by-now all-but-obligatory Republican refrain that the mandate is “unconstitutional.” This capitulation reflects a general shift to the right in American politics; what just a few years ago was considered a moderate Republican alternative for health reform has now become the mainstream Democratic proposal.

Though Remedy and Reaction does not break a lot of new ground, it pulls together a remarkable amount of material while tracing the tangled threads that run through our health-policy debates. The prognosis it delivers is in the end a bit murky. On the hopeful side, Starr demonstrates that effective political leadership can in fact overcome our antigovernment attitudes and the obstacles posed by our complex system of political institutions. It is not yet clear, however, whether the remedy offered by the PPACA will withstand the reaction to come. What does seem clear—alas—is that many elements of our health-policy “trap” will be with us for some time.