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Journal of Health Politics, Policy and Law 29.4 (2004) 969-1004



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Reprivatizing the Public Household?

Medical Care in the Context of American Public Values

Yale and Rutgers Universities
Whoever provides medical care or pays the cost of illness stands to gain the gratitude and good will of the sick and their families. The prospect of these good-will returns to investment in health care creates a powerful motive for governments and other institutions to intervene in the economics of medicine.
—Paul Starr, The Social Transformation of American Medicine

As it unfolds, The Social Transformation of American Medicine (1982) becomes progressively less about medicine and more about America. Of course the two stories are intertwined throughout the book. As Paul Starr explains to his readers early on, "It is not possible, as I see it, to understand the origins of the power of the medical profession, in the face of all the other political and economic forces at work in health care, without reference to its cultural authority" (9). To understand cultural authority, one needs to understand the culture from which authority derives (Krause 1996). Professional identity had to be constructed differently in the United States than in Europe, influenced early on by the Jacksonian era distrust of elites, bolstered by widespread suspicion of corporate motives in the Progressive Era, and protected from encroaching federal intervention by the fears of the Cold War. The echoes of each of these historic episodes [End Page 969] still resonate today, shaping contemporary values and attitudes toward the medical profession (Schlesinger 2002b).

As book two develops, Starr's narrative shifts from the profession itself to the projection of medical authority into the political arena. Doctors remain the protagonists, but no longer are they the sole focus of the historical spotlight.1 As the stage shifts, so too does the frame of reference. The narrative becomes less connected with American culture and more attentive to political maneuvering. As the epigraph above suggests, Starr characterizes policy making as a contest among self-interested elites, each jockeying to win the allegiance of the citizenry. Cast in these terms, public concerns matter less than politicians' strategies. The narrative becomes less focused on the factors that make health care distinctive, emphasizing instead the ways in which health policy mirrors broader social policy. In so doing, the book is transformed from a nuanced portrayal of a heterogeneous American culture into a dyadic struggle between political ideologies. The book becomes less a story about America and more a tale about simplified images of America, as portrayed by political elites seeking to expand their own base of influence. A complex narrative is displaced by shadow-play, a sort of Punch-and-Judy contest between liberals and conservatives intent on persistently bashing one another's position.

This simplified rendition is nonetheless applied with considerable insight. It is in this context that Starr develops some of his most memorable predictions about (what was then) the future of American medicine. In the book's penultimate chapter, he foretells "the reprivatization of the public household" (417). This brief section, running all of three pages, nonetheless plays a crucial role in the book's narrative. The depiction synthesizes the themes of growing collective involvement in medical care, the key focus throughout book two, into the evocative notion of a "public household." It warns of the threat—more dramatically, of the impending demise—of this fifty-year liberal agenda in the face of a growing emphasis on individual responsibility and market choices, strategically deployed by conservative elites. In prophetic terms, it describes the "three revelations" of conservative leaders and maps out their portent for American health policy.

As a social prognosticator, this was Starr at his finest. He accurately foretold the evolving conservative political agenda, capturing perfectly both its tone and its implications for health policy. Although he is less precise [End Page 970] about how these strategies are expected to shape public sentiment, he clearly anticipated a turn against government involvement in medical care, one apparently...

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