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

In his most recent book, Paul Starr displays his customary erudition and literary grace. He also warns in the first sentence of the Preface and Acknowledgements that he writes “as a historian and sociologist … as an advocate for changes in national policy … [and as someone who became] involved in some of the events I would otherwise have studied at a distance” (p. xi). Readers should heed this warning.

The first two sections of the book are likely to be useful to historians. In part 1, “The Genealogy of Health-Care Reform,” Starr takes account of selected scholarly publications since his prize-winning account of health reform in the United States, The Transformation of American Medicine (1983). These chapters are a credible introduction to the history of health care reform from the Progressive Era to the election of President Clinton in 1992.

Part 2, “Frustrated Ambitions, Liberal and Conservative,” an account of health policy in the United States from 1990 to 2006, is less persuasive. In a chapter titled “The Shaping of the Clinton Health Plan, 1990–1993,” Starr combines wide reading in primary and secondary sources, strong personal opinions, and information he acquired as a member of the White House staff during the failed effort to achieve reform in Bill Clinton’s first term.

He concludes, perhaps self-servingly, that “[i]f Clinton had left health-care reform to Congress, legislation would likely have been still-born” (p. 108). However, he does not mention White House rejection, in the summer of 1994, of draft reform legislation that had strong bipartisan support. Similarly, he ignores initial resistance by Hillary Clinton and White House staff three years later to what became the State Children’s Health Improvement Act. At the end of part 2, moreover, he understates bipartisanship in drafting and enacting the Medicare Modernization Act of 2003 (MMA). Perhaps he does this because acknowledging the full legislative history of MMA could detract from his central theme that by 2006 the “stage was set for new battles in the long-running ideological war over health care” (p. 158).

This war is the subject of part 3, “Rollercoaster,” in which Starr discusses the history of the Affordable Care Act of 2010 (ACA). He grounds part 3 in journalistic accounts and what seem to be a relatively small number of interviews. First he describes “The Rise of a Reform Consensus, 2006–2008.” Then he summarizes published accounts of the struggle to enact the ACA in 2009–10. Next he speculates about “Why Health-Care Reform Passed (and Climate Reform Didn’t).” In the chapters that conclude the book, Starr speculates about the ACA as “public philosophy” and uncertainties about its survival.

Starr’s account in part 3 was soon superseded by John E. McDonough, Inside National Health Reform (2011). McDonough participated in negotiating about and drafting the ACA as a staff member for the late senator Edward Kennedy. He had previously chaired the insurance and health committees of the Massachusetts House of Representatives and written two books on health policy published by university presses. Starr cites a 2010 interview with McDonough about health reform in Massachusetts (p. 295).

If journalism is the first draft of history, in the familiar cliché, Starr and McDonough have written helpful second drafts. Subsequent historians are indebted to such contemporaries because they use the methods of scholarship to study events of substantial importance.