Reforming the past: the challenges faced by Obamacare
Authors: Saurabh Jha
Journal: Journal of the Royal Society of Medicine (2013)

Starr, P. Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform. New Haven, CT: Yale University Press, 2011.

To the casual observer across the pond the American Healthcare system is an anachronistic, overly complex and needlessly inefficient money-sucking behemoth that, like the country, is awe-inspiring and perplexing in equal measures. Equally puzzling is the public opposition to the Affordable Care Act (ACA). Government-subsidized healthcare, imitation of the NHS; what is there not to like?

Paul Starr's1 Remedy and Reaction is a wonderful exposition of the maladies and a worthy sequel to his Pulitzer Prize-winning magnum opus, Social Transformation of American Medicine, which narrated the evolution of healthcare in the US contextually with the development of the nation.

America is unique. Not only is it the sole G7 nation with a considerable chunk of the population without healthcare coverage but it also curiously equates government involvement in healthcare with loss of freedom. However, Starr is dismissive that socialized medicine is singularly at odds with the American psyche. After all, no politician would dare rescind Social security and Medicare. No one objects to public education on the grounds that it is ‘socialized education’. If none of these public programmes is inimical to the American values of liberty and minimal government why healthcare?

Although special interests, such as the American Medical Association, lobbied against government involvement in healthcare at various times, the author rejects the conventional and convenient narrative of a battle line between special interests of the industry and a suffering population, which is generally emblematic of the corporate world. This model does not apply to US healthcare in large part because the interest groups are not monolithic but a patchwork.

The American healthcare financing was landscaped unintentionally by a war time regulation. Wage ceilings imposed during the World War II forced employers to offer fringe benefits such as health insurance to entice workers. Employer-based insurance pre-taxation is now the norm. Many employees enjoy a high level of medical care while shielded from its marginal costs. Unsurprisingly, this group, a not insignificant proportion of the population, fiercely opposed healthcare reform.

Indeed, the opposition to the ACA came not from rugged individualists; the live free or die brigade, too proud to receive government help. The main opposition came from people who feared that their access to medical care would be inconvenienced by government involvement; ‘members of an entitled majority with a privileged position in the public-subsidy system’. The irony was deliciously crystallized in a Tea Party placard which read ‘Hands off my Medicare’. The Tea Party, of course, advocates limited government.

The heart of the gridlock is the unique American political system with its checks and balances. Meaningful reform is possible on rare occasions when there is both political and ideological union in Washington. Even at such moments of resonance, political expedience necessitates compromise. Compromise means change by increments rather than a radical restructuring. Incrementalism has resulted in a complex healthcare financing system, a leviathan too large to simplify; a ‘policy trap’ that protected enough of the public to resist change.

Complicated politics reflect complicated moral values. Starr identifies the crux of the problem: ‘Americans are egalitarian as well as individualist, but in health care as in many other areas, their values often point in opposite directions’.

Unlike other western democracies where access to healthcare preceded medical facilities, in the USA it was the opposite; capital investment in healthcare was raised before extending insurance. In other words, investment has preceded equality. If the ACA attempts equality it will be confronted with Sophie's choice: expensive care for all or rationed care for some. The ACA has avoided the ‘R’ word; wise given its propensity to mutate into the etymologically more sinister kindred ‘Death Panels’.

Instead of explicitly focusing on costs the ACA emphasizes evidence, quality and safety. Funds have been set aside for comparative effectiveness research. Ostensibly with the ethos: let them have cake if cake is evidence-based. The author does not venture to forecast the ACA's ability to bend the cost curve, leaving the reader's optimism or lack thereof in such an accomplishment largely undented.

Many argue that the Obama administration passed reform in haste, at a time when government should have focused on the economy. Perhaps the president learnt from history. Franklin Roosevelt was well positioned to pass universal health care, but prioritized initiatives that were more urgent in the Great Depression. Clintonian plan imploded in attempting to please the insatiates on the left, who wanted nothing less than a single payer system, and on the right, who believed that the employer mandate for insurance should remain the primary means of financing universal healthcare coverage.

The reader may view the ACA a far less radical a reform than the political rhetoric in the USA suggests. It is an increment on existing regulations and programmes. Its blueprint was developed in Massachusetts during the tenure of the recent presidential challenger.

The ACA has the dubious distinction of being vilified for both over-reaching and not reaching far enough. This is the beauty or, depending on your point of view, the tragedy of the diverse American political spectrum.

US Healthcare is both fascinating and peculiar but is less irrational when one understands the politics, the conflicting values and the contextual history of the USA. This understanding is a rewarding exercise. Starr connects the disparate dots with the fine prose befitting of an impartial historian and sociologist.