Remedy and Reaction: The Peculiar American Struggle over Health Care Reform (review)

In this book, Paul Starr, formerly a senior White House health-policy advisor for President Bill Clinton, examines the failure of the United States to adopt national health insurance in the past century. He begins by reviewing major developments in the history of national health insurance. In 1915-19, efforts to adopt European-style national health insurance systems failed to gather support. In the 1930s and 1940s, efforts to include national health insurance in New Deal programs foundered because of higher priority for Social Security and unemployment insurance and the opposition of organized medicine and other interest groups. The 1940s and the 1950s saw the widespread adoption of commercial group health insurance by employers and labor unions. These programs excluded the elderly, a growing proportion of the population, and the poor. In 1965, Congress enacted a two-tier system with Medicare as a national health insurance program for the elderly and Medicaid as a joint federal-state program for welfare recipients. The uninsured in 1970, mostly the working poor and their families, comprised less than 12 percent of the population.

In the early 1970s, President Nixon made two unsuccessful proposals for expanding health insurance coverage and Congress took the first of many steps to add new groups to Medicaid coverage. In the 1980s, new systems of cost control for hospitals and physicians demonstrated the decreasing political power of both groups. Employers offered managed care policies as options for their employees with government encouragement. These and other incremental expansions of health insurance diminished the opportunity for comprehensive national health insurance.

In 1992, President Bill Clinton supported national health insurance in response to rising health-care costs that adversely affected workers covered by employer health insurance and others. However, disagreements within Congress and among involved groups prevented the enactment of any broad programs. Clinton did effect a separation of Medicaid from welfare that enabled it to provide more services to more people. In 1997, a State Children's Health Insurance Plan (SCHIP, later CHIP) provided grants to states for the care of children just above Medicaid standards. During this era also, managed care lost much of its appeal to the public. The administration of President George W. Bush produced the Medicare drug benefit program, which raised health-care costs.

Opportunity for national health insurance improved in 2006 when Massachusetts, under Governor Mitt Romney, enacted the first near-universal health insurance program. In 2010, President Barack Obama was able to pass a health plan based on Medicaid that extended coverage to millions of uninsured persons. The legislation accepted a conservative principle that insurance should cover only unexpected costs by subsidizing a low level of basic insurance. It accepted a liberal principle by including preventive care and a wide range of services. It required individuals to maintain a minimum level of health insurance while simultaneously denying insurers the right to refuse insurance based on pre-existing conditions or to charge premiums based on individual health.

Most of the book examines proposals for health-care legislation during the Clinton, Bush, and Obama administrations. It does not systematically describe the changes in any specific program during any period. The analysis focuses on Congress, the presidents, and interest groups and ignores federal agencies. This book is useful for its insights into the thinking and actions of the participants at each stage of planning for national health insurance.

Starr, like many other writers, does not place the history of national health insurance in the context of the history of medical care. Before the sulfa drugs in the late 1930s, national health insurance would have produced little improvement in health care. Effective drug therapy was limited to a few diseases and nutritional deficiency disorders. Surgery was often inappropriate or foolhardy and was seldom performed by full-time surgeons. Most physicians were deficient in their medical knowledge. The primary contributions to better health in that period were sanitation, public health programs, school health...