The signing into law of the Affordable Care Act by President Obama in March 2010 was a signal achievement, one of only a few successful attempts made over the past century to reform the American health care system.
The structural problems facing our health system were formidable and included problems of access, cost, and outcomes. At any given moment, 50 million citizens lacked insurance. While the American system consumed 17.6 percent of GDP, the outcomes it delivered were inferior to those of several countries that spent half as much. Although many grasp how big these and other problems were, and remain, fewer understand how we arrived at our present situation. There also continues to be confusion about the scope of the national plan, and widespread disagreement about what to do about those parts of the system that still need fixing.
Paul Starr, professor of sociology and public affairs at Princeton and one of President Clinton’s senior health policy advisers during his ill-fated attempt to reconstruct our health system, has written a surprisingly interesting and engaging account of the many attempts made over the past century to reform care in this country. As daunting, even wonkish, as this may sound, Starr does an excellent job of explaining the different proposals and identifying the reasons why some succeeded where others failed so spectacularly.
The tenor of the debate over the role of the US government in health care indicates just how firm and far apart are the beliefs and ideologies that underpin the different positions. Starr notes that although many demonize robust government involvement as “socialized medicine,’’ one does not hear public schools described as “socialized education,’’ though they are funded through taxation. Why then, he asks, do passions rise so heatedly over involving the government in making health care more accessible and inclusive; reducing its costs; and pushing the system to improve outcomes? His answer is that these are not merely differences of opinion but opposing world views.
This is the real strength of the book. After the first seven chapters, which contain descriptions of congressional negotiations that would please even the most avid C-SPAN devotee, Starr steps back and examines the health care initiative as a manifestation of political philosophy. In doing so, he gives valuable insight into what has driven those who have supported or opposed reform across the decades up to and including the most recent struggles. Starr’s balanced and thoughtful analysis is of a sort increasingly difficult to find in today’s polarized media, whose coverage is often designed to confirm, not challenge, the convictions of their audiences.
In the current dialogue of the selectively deaf, which often passes for political discourse, even the same words can have different meanings. Starr uses the word “freedom’’ and how it is applied to the individual mandate - the obligation of individuals to purchase health insurance - as an example of this. Some hold the individual mandate to be yet another form of government intrusion into decisions which private citizens should be free to make on their own. Others hold that freedom from disease is no less important than freedom from governmental intervention, and that without an individual mandate not enough will pay into the system, leaving insurance too costly for millions, and denying them access to care.
In clearly presenting the approaches toward reform, Starr frames them in ways that are necessary for constructive dialogue on how to continue. And continue we must, for although the plan was made into law, there are many who call for its repeal; and while the current plan addressed some important problems, it left many more unsolved.
Dennis Rosen, a pediatric pulmonologist, can be reached at firstname.lastname@example.org.