Health Reform Without Apology

The Affordable Care Act is under relentless attack from conservatives. Yet progressives are too ambivalent about defending it.

The passage of health-care reform in March 2010 is the most progressive expansion of U.S. government social policy in nearly half a century and perhaps without parallel in its scope since Social Security’s enactment in 1935. The law—the Patient Protection and Affordable Care Act (ACA)—expands access to medical care and health insurance to more than 30 million low- and middle-income Americans; imposes much of the cost on affluent individuals and businesses; terminates longstanding practices by parts of the private insurance industry that victimized millions of sick Americans even after they’d paid premiums for decades; elevates health and prevention as a priority; and launches the most comprehensive set of initiatives and experiments to date to restrain both government and private-sector expenditures on medical care and claw back inefficient spending to help pay for widening access.

Today’s partisan vitriol readily explains why Republicans vociferously oppose the ACA, even though core components (like the individual mandate) were hatched years ago by Republican policy-makers and conservative think tanks like the Heritage Foundation. What is surprising is the reaction of many progressives, who are subdued about or even hostile to the new law, lamenting it as inadequate and overly accommodating to vested interests. Twenty-six percent of Americans favor repealing the ACA because it did not go far enough, according to a Politico/George Washington University poll in May.

Progressive disaffection with the most liberal social welfare legislation in at least a generation may stem from the failure to enact single-payer financing or a compulsory national public option. Some skeptics focus on the inadequacy of the ACA compared to health-care systems in other affluent democracies. But most people and many progressives are disaffected—at least from my talks to community, business, and university audiences—because they are unaware of what the ACA did enact. When I describe the actual provisions in the ACA, I am repeatedly asked, “How come I haven’t heard that before?” Fair question.

Remedy and Reaction comes at an opportune time to break through the misunderstandings and falsehoods about health reform, and its author, Paul Starr, is ideally positioned to take on this daunting responsibility. Starr is a founding co-editor of The American Prospect and author of The Social Transformation of American Medicine, a deservedly well-regarded history of American medical care and health policy that won the Pulitzer Prize in 1984. Remedy and Reaction concisely explains what often seems inexplicable—why about 50 million Americans lack health insurance even as the country leads the world in health-care expenditures, accounting for more than 17 percent of GDP.

Remedy and Reaction’s comprehensive history of health-care reform from the early twentieth century through the passage of the ACA traces the slow, torturous, and often futile efforts of reformers to expand health insurance to all Americans. Reform was persistently obstructed by conservatives and the swelling army of interests devoted to protecting the status quo by exploiting James Madison’s byzantine institutional miasma and the fissures within both parties (especially the Democratic Party). Opponents repeatedly defeated national health insurance and shaped the reforms that were passed, imprinting significant new programs with the constraints, limitations, and selectivity demanded by stakeholders and political coalitions.

The “perennial disappointment” of liberals who sought health insurance for all has a long history, beginning at the end of the Progressive Era, when European interventions gave impetus in the United States to national and state reform efforts (instigated by the expert-led American Association for Labor Legislation) that were blocked by divisions among allies (including labor) and by the insurance industry—even before it had established a giant stake in the sector. The Great Depression created the extraordinary opportunity that accompanies extraordinary crisis, but Franklin Roosevelt judiciously held back on national health insurance to ensure passage of Social Security in 1935, and though they tried, he and successor Harry Truman never enjoyed a similar opening again.

Reformers regrouped in the late 1950s around what became the Medicare legislation that Lyndon Johnson signed into law in 1965—an approach that scaled back progressives’ universal aims in favor of covering hospital care and associated physician services for those on Social Security and solidifying a federal-state program for the indigent (Medicaid). Starr describes this episode as representing a “brilliant [political] coup” for LBJ, but “not exactly a liberal one.” Medicare, Starr reports, became a “source of the persistent inequalities and high costs of the American health-care system.”

Remedy and Reaction then charts the stalemate and incremental reform of the nearly three decades following Medicare’s passage. Comprehensive reform was scuttled by ideological battles between the parties and divisions among Democrats as well as by fiscal constraints. But reform did not stop. Starr highlights the “unexpected course” pursued by Ronald Reagan, who talked of dismantling the New Deal but signed on to substantially expanding Medicaid and created direct federal control of Medicare’s reimbursements, which began with hospitals and was widened by subsequent presidents to physicians and outpatient services. (In a striking historical paradox, Reagan’s inauguration of this government payment system for Medicare created the precedent for later progressive proposals for rate regulation that would extend to private providers.)

The book devotes extensive attention to the defeat of Bill Clinton’s effort—one in which, Starr notes, he played a role as an adviser. His recounting of the well-known context and contours of Clinton’s effort offers a fair enough guide to readers who are just coming to health reform or care to relive the trauma of 1993-94. Starr acknowledges the missteps by the Clintons but assigns the balance of culpability to the “center fail[ing]”—the “deals that were never closed… compromises never reached, [and] backpedalling by Republicans, moderate Democrats, and key interest groups that abandoned proposals they had earlier endorsed.”

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