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Health Care on Life Support

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Review of Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform. By Paul Starr. Yale University Press. 324 pp. $28.50

A liberal United States Senator, let's call him Edward M. Kennedy, dies. When he gets to heaven, he asks God, "Will America ever have national health insurance?" "Yes," the Lord replies, "but not in my lifetime."

Change the name, and the joke applies to just about every decade of the twentieth century. Given the imperfections in and the uncertain fate of the Affordable Care Act of 2010, which faces challenges in the courts and in Congress, it may well keep Americans laughing with tears in their eyes for a long time to come.

In Remedy and Reaction, Paul Starr provides a clear, comprehensive, and compelling chronicle of the health care debate in this country from the Progressive Era to the present -- and a probing and provocative analysis of a costly and complex health care system that leaves tens of millions of Americans unprotected.

He brings superb credentials to the task. A professor of sociology and public affairs at Princeton University and an adviser to President Clinton, Starr is the author of The Social Transformation of American Medicine (which won the Pulitzer Prize), The Logic of Health Care Reform, The Creation of the Media, and Freedom's Power.

Starr is at the top of his game in Remedy and Reaction. The United States, he notes, is the only advanced society that does not provide health care to all its citizens. Although Americans spend two and a half times more per capita than other rich countries treating disease, the World Health Organization has ranked our system thirty-seventh.

Explanations for our failure to fix it include, of course, an animus against government that manifests itself in bitter partisan conflict in Washington, D.C. And yet, Starr reminds us, the American people and its politicians have reconciled their values with government-funded social welfare policies such as Social Security and Medicare. Health care is different, he argues, because the nation has fallen, unwittingly, over the last half century, into a "policy trap." A system has evolved which leaves millions of Americans uninsured against illness while satisfying enough people to immunize it against change. The key elements of the trap include employer-based programs that hide their true cost from beneficiaries and taxpayers; popular government programs for the elderly and veterans, who are well-organized and believe they have earned their benefits; and a financing system that has enriched the health care industry, which has created powerful lobbies to resist reform.

Taking on a subject where the devil is in the details, Starr manages to make his analysis accessible without dumbing it down. And Remedy and Reaction contains important lessons for liberals. Although single payer plans may be simpler and more efficient than the alternatives, Starr makes a compelling case that they were -- and are -- non-starters for Bill Clinton and Barack Obama. In 1994, well before the economy tanked and the Tea Party was founded, he notes, California voters defeated a single-payer initiative by a whopping margin of 73 to 27 percent.

Starr also warns liberals against making "the public option" (a government insurance plan) a litmus test of the worthiness of health care reform. If it were not keyed to low Medicaid rates, he points out, the public option might not be cheaper than private insurance. Nor would it necessarily attract a large enrollment. Moreover, private companies could use it as a dumping ground for people with chronic illnesses and disabilities.

Starr makes a compelling case that liberals should re-consider their lukewarm response to the Affordable Care Act. Rarely, he writes, has so far-reaching a reform been so widely dismissed by those who supported it. Acknowledging that the legislation does not do nearly enough to reorganize how medical care is delivered or to contain costs, Starr shows that it provides coverage to about 32 million people, half through Medicaid and half through private carriers, raising the insured share of the population to 94 percent. Unlike George W. Bush's prescription drug bill, "Obamacare" does not raise the federal deficit.

By delaying implementation of key components of the legislation, Starr argues, the Democrats created a huge problem for themselves. Even though it was originally a Republican idea, the "mandate" (a requirement that every individual purchase a minimum level of coverage) compounds those problems.

In theory, critics who argue that if the government can force citizens to buy health insurance they can force them to buy other things, are easy to refute. After all, Starr indicates, there are "clear grounds" for distinguishing health care from other goods and services. If you appear at an electronics store on Super Bowl Sunday you won't be given a plasma TV on demand, for example, but you can go to a hospital emergency room and expect treatment. In essence, then, we have a mandate now -- but it is inefficient and unfair.

Given our toxic political climate, which pumps oxygen into demagogues and liars, Republicans will surely run against "Obamacare" in 2012 -- and repeal it if they win. They'll get traction, Starr implies, because opposition to reform comes not only from pharmaceutical companies, hospitals, and insurance providers, but from members of an "entitled majority with a privileged position in the public subsidy-system." If "they" -- and I mean "we" -- don't set aside narrow self-interest and summon "elementary decency" toward those with the bad luck to get sick, universal access to health care, which ought to be a basic right in a democracy, won't be enacted in our lifetimes.