The Clintons’ long shadow (a brief review of Paul Starr’s Remedy and Reaction)

Do yourself a favor. Though it isn’t due out until early October, pre-order Paul Starr’s Remedy and Reaction right now (here).  You’ll thank me later because it is good. In fact, it’s the best summary and political analysis of health care reform I’ve read.* I say that for two reasons: (1) At about 280 pages (excluding end notes), it is relatively concise for the subject and span covered (the political history of U.S. health reform, with principal focus on developments from the 1970s through April 2011); And (2), Starr nails every nuance while taking the analysis one level deeper than any other treatment I’ve read.

Here’s an example and something I had not, myself, considered: the Clintons may deserve more credit for the ACA than they’re given.

Perhaps the crucial difference between the Clinton and Obama efforts was that in 2009 all parties knew how the story had ended in 1994: Congress did nothing and the Democrats suffered a historic defeat at the midterm elections. In 2009, Republicans were looking to reenact the past and Democrats to avoid repeating it. Rather than enter into negotiations or offer a serious alternative, the Republican congressional leadership sought only to block the Democrats. [… T]he predominant response [among Democrats …] was to press ahead and correct what they now saw as earilier failings. […] This time, rather than wait for the opposition to mobilize, unions and other liberal groups took early steps to create an extensive field operation to build popular support for the struggle ahead. […] The seeming lessons of 1994 were also not lost on the right flank of the party. The conservative or “Blue Dog” Democrats […] did not split their party’s ranks by lining up behind an alternative bill as they had 16 years earlier, and enough of them voted for the legislation to enable it to squeak through. If the Health Security Act had not failed in 1994–and if Democrats had not interpreted its failure as a reason for their losses that year–The Affordable Care Act probably could not have passed in 2010.

[T]he Clinton experience also affected Obama because of an accident of political history. He ran into Hillary Clinton on his way to the Democratic presidential nomination, and the race between them, rather than being settled quickly, was drawn out for months, forcing Obama to debate Clinton 21 times. The debates usually turned to health care, a subject that Clinton knew thoroughly from her role in the reform effort of the early 1990s. […] Clinton’s formidable knowledge and debating skills forced [Obama] to master health policy. […] And then when he entered the White House, not only could Obama hold his own on health policy with the experts; he was also far more committed to health-care reform than anyone had had a reson to expect when he first became a candidate.

Here’s one more example in which Starr corrects the historical record of failed attempts at reform. Again, he returns to Clinton.

T.R. Reid writes, “From Theodore Roosevelt to Barack Obama, half a dozen U.S. presidents have come to office promising ‘health care reform’ and ‘universal coverage'”; Reid then refers to “the Roosevelt, Wilson, Truman, and Nixon reform plans.” But this picture is wrong. Teddy Roosevelt never addressed the problem when he was president, and there never was a Roosevelt plan. Wilson never supported health insurance in any form and there never was a Wilson plan. Harry Truman called for national health insurance in principle but never submitted or endorsed legislation. Nixon was the first to submit legislation, but as a defensive maneuver in 1971 in preparation for his reelection campaign the following year, and then as a desperate move in 1974 when he was trying to save his presidency during Watergate. Carter also only submitted a plan late in his term, in his case to ward off a challenge form Kennedy in the Democratic primaries.

What president was the first to “come to office promising ‘health-care reform'” and to propose legislation for “universal coverage”? That would actually be Bill Clinton in 1993.

That’s not to suggest that Remedy and Reaction is all about Clinton. It isn’t. The excerpts above just happen to highlight the Clintons’ role in health reform and illustrate the knowledge of and sensitivity to political and legislative history that Starr brings to bear. The overarching thesis has little to do with Clinton, directly. It’s that America has found itself in a policy trap. Having subsidized insurance for most voters — workers (through the tax exemption of employer-sponsored plans) and seniors (Medicare) — many find it hard to see any self-interested reason to pay for coverage expansion. This is not a trap in which other industrialized nations were ensnared, and it dramatically complicates the arguments for health reform and universal coverage in the U.S. (which was my point in a post last week).

It’s tempting to say that Remedy and Reaction is the sequel to Starr’s Social Transformation of American Medicine (about which we’ve posted many times here). And it is true that it advances the story of American health policy — or part of it — from the early 1980s, when STAM ends, to today. But the focus is health reform with an eye on the (largely) health insurance reform enacted in 2010. Consequently, many other developments that altered the landscape of U.S. health care are not as fully addressed.

This is both a limitation and a strength of Remedy and Reaction. It is not a full on analysis of all things health care in American over the last 30 years. On the other hand, that keeps the book relatively focused, making it readable in a few days (or one long one, perhaps). In contrast, for me, STAM was weeks of hard work, though it too was well worth the effort.

* Full disclosure: Yale University Press sent me a free, advanced copy of the uncorrected page proofs.

Hidden information below


Email Address*