Earlier this year, the Penn campus received a visit from one of the nation’s most prominent sociologists of medicine and health care –- Paul Starr, PhD. As Joshua Metlay, MD, PhD, professor of medicine and epidemiology in the Perelman School of Medicine, said in his introduction, Starr’s Pulitzer Prize-winning book, The Social Transformation of American Medicine (1982), “is the mandatory starting point” in discussions of health care’s future and health care’s reform. As the Republican presidential primaries show, that topic remains one of the most important issues in the nation. Starr is a professor of sociology and public affairs at Princeton University.
The event, hosted by Penn’s Leonard Davis Institute of Health Economics, drew a large and expectant audience of physicians, economists, students, and administrators. Starr’s topic was the tangled and contentious history of health care reform in America. At the start, he noted that the fate of the Patient Protection and Affordable Care Act of 2010 “is completely open”: it may survive, it may die, or it may be substantially revised. What has always surprised him, he continued, is “the rancor in our conflict,” which is not found in other democracies. Outside the United States, the focus is on ensuring that costs are spread widely. Only in the United States, Starr asserted, is such an initiative equated with a loss of freedom –- and the politics of health care has become more acrimonious over time.
For a period in the 1990s, Starr was not only a student of health care but an advisor as well, when he spent time in the Clinton White House. As Starr put it wryly, “I got into the middle of the crossfire.” Going in, he felt that, in academe, “people trust each other’s good faith,” even when they disagree. That, he discovered, was not true in politics.
In his talk, Starr presented the struggle for health care reform as “a historical drama in three acts.” Each scene begins with optimistic reformers. In fact, early in the 20th century, New York State came close to much broader health care coverage. Franklin Roosevelt felt he did not have enough Congressional support to pass a health care bill, but Harry Truman did propose a program of universal health insurance. The proposal was defeated by the American Medical Association and insurance companies, who compared it to “socialized medicine,” even Communism. Those against such programs, in Starr’s words, “had developed a script of opposition,” inspired by the Cold War. Universal coverage was depicted as inimical to American life, something foreign.
Act II ranged from the 1950s to the Nixon Presidency. Supporters of broader health insurance coverage built on the Truman bill. In 1965, Lyndon Johnson signed Medicare and Medicaid into law. What Congress passed, however, greatly increased the costs of health care –- to a great extent because of concessions to the A.M.A. But history took a couple of sharp turns. In the midst of the Watergate scandal, a weakened Nixon was looking to redeem himself and was in favor of a broad plan. Wilbur Mills was then the powerful Democratic chairman of the House Ways and Means Committee, and his backing was essential to Nixon’s plan. But Mills’s legislative power was undermined by scandal. According to Starr, the opportunity for bipartisan support disappeared.
Act III, as Starr presented it, began during the Clinton years, through the years of the Republican Congress, and into the Obama administration. In that period, health care insurance was “at the top of the agenda for Democrats.” But there was also “a cacophony of different ideas,” said Starr, even within Clinton’s own party. Despite some initial headway toward a bipartisan agreement, “it all came to ruin.” The limits on expenditures and attempts at cost containment worried business groups. Starr also noted that at this time, Republicans supported an “individual mandate” –- which two decades later they are vilifying. And speaking of turnabouts, in 2006, universal coverage was enacted in Massachusetts through the efforts of Governor Mitt Romney, with advisors from, among other resources, the conservative Heritage Foundation.
For his part, President Obama did not have to devise a plan but could build on others. That, as we have all seen, did not make the path to passage any easier. Starr noted “the wild ups and downs,” with raucous town hall meetings, and getting enough Congressional votes was a “cliffhanger.” Despite the passage of the Affordable Care Act, “we know that it isn’t over” only two years later. A presidential election looms; the Supreme Court will scrutinize the act; and some states are pondering their own challenges. As Starr put it, “It’s gonna take another miracle” for the Act to survive in an era when the political parties are much more ideological and swings in power could bring significant changes in policy.
In the question-and-answer period, Starr conceded the legitimate achievements of the last two years but expressed concern about “the slow timetable for implementation.” Some parts of the Affordable Care Act would not go into effect until 2014. If the act allowed for consolidation by 2013, Starr said, there would be a better chance that it would survive, even with a change of political power. According to Starr, it would be very difficult to take health insurance away from the 30 million people who gained coverage through the act.
It is not surprising that someone who served in the Clinton administration would be in favor of health care reform. But Starr also believes that supporters must do a better job in explaining the act. As in the early 1990s, the initial outlook for health care reform today was very good; then the opponents went to work, and public opinion dropped. In the end, many Americans are confused about what reform entails. Today, Starr said, many families are more opposed to the Obama plan, even if it would benefit them. As he said in concluding his remarks, the historical drama of health care reform may actually be “a kind of tragedy.”