In his first book, "The Social Transformation of American Medicine" that won the 1984 Pulitzer Prize, Paul Starr wrote a sweeping history of "the rise of a sovereign profession and the making of a vast industry." It chronicled the evolution of the medical-industrial complex that shaped the nation's unique approach to medicine -- an approach that ultimately came to view the patient as almost an afterthought to the process of generating corporate profits.
In his latest book that he discussed at the 2012 Wharton Alumni Health Care Conference,
Paul Starr's first book (top) won the 1984 Pulitzer Prize. His new one chronicles the century-long history of America's political battles over health care reform.
Starr tells the story of a parallel track of activity throughout the same century: the tangled political wars fought over the reform of that health care system.
The Princeton Professor of Sociology and Public Affairs' new "Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform" begins with this scene-setting observation:
"By the second half of the twentieth century, the United States was the only major advanced society without a system for providing health care for its citizens... As a result of the various limitations of the insurance system, Americans experienced forms of economic insecurity virtually unknown in the other advanced countries: 'medical uninsurability,' 'medical bankruptcy,' and 'job lock.'"
"We have a problem that has evolved out of this," Starr told the conference of MBAs in Wharton's Huntsman Hall on the University of Pennsylvania campus. "It is what I call in this book a politically treacherous national imperative. It is an imperative to change the system."
"Among those rich nations of the world," Starr continued, "the United States stands out in healthcare not only because we spend so much more on healthcare than any of our peers. Not only because the United States has long been the only country of the major democracies without universal coverage. But also because of the duration and the sheer rancor of the conflict over this issue. We have been fighting over healthcare for just about one hundred years and in none of the other major democracies is healthcare a central flash point of ideological conflict. There are differences over policy but it is not the kind of toxic political issue that it has become in the United States. Conservative parties elsewhere accept the principle of shared social
A 5:34 video excerpt of Paul Starr's remarks at the Wharton Health Care Management Alumni conference. Or, click here for larger video format.
responsibility for the cost of illness... It's only in the United States that conservatives make the following equation for health care: Public financing equals a loss of freedom. That's a distinctive aspect of American health care politics."
"Years ago," said Starr who served as a White House health care advisor during the Clinton administration, "many of us believed there was some consensual way that we could arrive at a resolution of this issue that would make everybody happy. Now, I very much doubt that any such kind of consensus solution exists."
Health reform in three acts Starr then went on to present a history of what might be thought of as a century of America's health care reform effort in three acts.
"The first act takes place in the first half of the twentieth century," he said, "It has three scenes: the first is just before World War I, the second under Franklin Roosevelt and the third under Harry Truman."
"At the beginning of each scene, reformers believe their opportunity is at hand, that legislation will be passed but in each case, things come crashing down in failure," Starr said.
Some of Roosevelt's advisors wanted to include health insurance as part of Social Security legislation in 1935, but that didn't make it.
"At the time of Roosevelt's death in 1944, his advisors were finishing a speech that called for national health insurance," said Starr. " Instead, Harry Truman gave that speech in the late 40s and became the first President to present such a proposal to the nation. But he did it at the point when the Cold War was intensifying and the AMA and other groups were able to sink that proposal as 'socialized medicine.'"
Medicare and Medicaid Act two of Starr's political narrative reaches a crescendo in 1965 as the landmark Medicare and Medicaid programs were being cobbled together in Congress and rolled out as the world's most complex health care payment systems, but they were limited to seniors and certain segments of the poor.
In 1974, the year of the Watergate scandal, then-President Richard Nixon, who was seeking to recoup favor with the American public, proposed a national health insurance plan that was broader and more generous that those later proposed by the Carter or Obama administrations. To pass, that Nixon plan required the backing of House Ways and Means Committee Chair Wilbur Mills.
"But it came to nothing," said Starr. "Nixon resigned in August and just a short time later Wilbur Mills's career came to a crashing end when it was revealed he had been having an affair with a flamingo dancer as well as problems with alcohol. Some of you may remember he ended up driving his car -- and the dancer -- into the Washington Tidal Basin. It was so ridiculous that the fate of healthcare then depended on the personal fortunes of Richard Nixon and Wilbur Mills."
Starr's third act of the health care reform wrangle opens scene one in 1992 as Bill Clinton wins the White House in an election in which the skyrocketing costs of health care had become a central issue.
'Bodies strewn all over' Starr, who became part of the White House events he would later chronicle in "Remedy and Reaction," remembered "Clinton was very committed to bringing health care reform about. But there was no consensus even among Democrats much less among the various interest groups involved in health care. And the President wasn't able to move legislation in Congress. This scene ended the way many of those scenes in grand opera end -- with bodies strewn all over the stage -- and mine was one of them."
By 2005, the scene had switched from Washington to Massachusetts. There, a rare confluence of events orchestrated by the insurance industry achieved a consensus of sorts with business leaders, then-governor Mitt Romney and the conservative Heritage Foundation for a state law creating a system of universal health care coverage based on an "individual mandate" -- a requirement that all residents acquire insurance.
The big scene in this era's act, Starr said, occurred in recent years when the Obama administration and Congressional Democrats pushed through national health care legislation that was, in many respects, a clone of the Massachusetts law. The conservative-driven GOP did a 180 degree turn to vehemently oppose the same concepts it had supported in Massachusetts. In the end, the issue went to the Supreme Court which, to the great surprise of many, upheld the Affordable Care Act and brought us to the situation we face today as conservative governors continue their effort to torpedo the state health insurance exchange systems that are crucial to the success of the ACA.
America's health care 'fog' Starr posits that the "act" of health care reform underway today is made all the more chaotic and unpredictable by an American public that "sees the problems in healthcare and the battles over it through a dense haze of uncertainty and confusion," he said. "It's what I like to call the fog of health care, rather like the fog of war. It prevents people from understanding in the moment the significance of events as they're taking place."
He believes the public's "huge misconceptions" about the Affordable Care Act do not forebode well.
"One of the things that pollsters repeatedly find is that the great majority of people have no idea what is actually in the Affordable Care Act," Starr said. "So we have this kind of combat taking place under this 'fog' and it is hard to be optimistic under those circumstances in the short term.
"I believe that if the political climate were less poisonous, we could actually work out an accommodation, but I'm not convinced this is our fate," he said. "For the moment it seems hopeless but in the long term there are possibilities and I don't think health policy is like a mathematical problem for which there is only one correct answer. When you look around, there are many countries that provide health care at an affordable cost. The United States could yet evolve its own distinctive solution based on our institutions and our politics."
"My hope," he concluded "is that after this long era when we have been adding to the complexity of the system, when we created this 'fog,' we can somehow get into a new phase of development where we consolidate programs, where we simplify things, where we model a system that is more coherent, more transparent, and ultimately provides good health care to the American people. Somewhere out there in the distance, I hope that possibility exists for us."
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Hoag Levins is a journalist and managing editor of The LDI Health Economist. hoagl@wharton.upenn.edu
