With the Supreme Court considering multiple challenges to the constitutionality of the Affordable Care Act of 2010 next week, OpEdge readers might want to delve into the long-term history of health care reform in the United States. If so, there is no better place to go than Paul Starr’s recent Remedy and Reaction: The Peculiar Struggle over Health Care Reform, which traces health care reform from the earliest proposals for government-sponsored health insurance just before and during World War I.
Starr is without a doubt the guy to tackle the subject. Since its 1984 publication, his Social Transformation of American Medicine has become established not just as the seminal work in the narrow field of health care, but as one of the very most important books of American social history. Since then, Starr has taught, conducted historical research into both health care and the media and served as a senior health care advisor for Bill Clinton. He is co-editor of The American Prospect.
Here are some of the insights that I gleaned from reading Remedy and Reaction:
A lost golden moment
There was a golden moment when all the stars were aligned for a major overall of the healthcare system which would have ensured that virtually every American had healthcare insurance. Both Republicans and Democrats pretty much agreed on what to do, the various constituencies such as insurers, physicians and the public were either on board or not opposed and the president in charge supported the idea and knew how to get things done. Unfortunately, the president was Richard Nixon and a potentially watershed moment drowned in the Watergate scandal.
Mitt Romney’s important role
Starr documents that the Affordable Care Act is profoundly the child of the successful Massachusetts plan that Governor Mitt Romney competently shepherded to passage and then efficiently implemented. The federal plan is derived from the same philosophy and using pretty much the same set of strategies and tactics as the Massachusetts plan. Starr also points out that Romney did not talk about healthcare reform during his gubernatorial campaign, but once in office he rolled up his sleeves and displayed enormous competence. Starr doesn’t say it, but I will: the Romney disavowal of his landmark accomplishment strongly suggests that Mitt is a value-free technocrat whose idea of being in charge is to implement competently the desires of his backers, whatever that means. By repudiating his own good works, Romney transforms himself from a major statesman to the ethical equivalent of an Albert Speer, that wonderfully brilliant architect and thinker who dedicated himself to accomplishing the will of his backers.
Not a socialist plot
Starr shows that the basic philosophy behind Obama’s plan from the beginning has been to cover more people and cut the cost of coverage while taking a pragmatic approach that does not profoundly upset the current complicated system that mixes public and private solutions and funding sources. Its dependence on private insurance and patient cost sharing derive from Republican ideas. So is the idea of not creating a “public option,” but instead establishing insurance exchanges, which are marketplaces for insurance for those not covered by government programs or their employers.
Like all compromises, there is something for everyone to hate and love about the Affordable Care Act. But Starr, who would probably have preferred a more European style system, brings up a stunning fact that should win the day with many centrists and progressives: The impact over Obama’s healthcare reform over 10 years will be to increase total healthcare costs in the United States by a worst-case 1 percent, while providing coverage to 32 million more people, or a little over 10% of the American population. By that math, the cost per person for health care goes down, which means that by applying some quick fixes to the current system, we cover many more people and at a lower cost.
It’s an imperfect law that doesn’t address all the challenges of perfecting an imperfect system, but it is nevertheless landmark legislation. Let’s hope the most right-wing Supreme Court since the Dred Scott days agrees.