An excellent and very informative history of government efforts to reform health care in the U.S., leading up to a brilliant analysis of the politics that shaped and (just barely) achieved the passage of the Affordable Care Act (aka Obamacare) in 2010. The second half of the book is fascinating, a political thriller that (like Spielberg's "Lincoln") lays bare the grubby political maneuvering that allowed the achievement of a morally desirable end.

As a progressive Democrat, I had though that Obamacare did too little, and gave away too much to health-care interests. This book made it clear to me that, in 2010, the sort of health care reform that progressives wanted was not politically possible. It also made it clear to me that Obamacare was a major achievement that will have increasingly positive effects over time -- an achievement that now seems likely to remain in place.

Given the enormous amount that has been written on current U.S. health policy, it is hard to know where to turn for analysis. Paul Starr's resume suggests that this book is a good place to start. He is an eminent expert in the field of public policy. He is a professor of sociology and public affairs at the Woodrow Wilson School at Princeton, co-founded the liberal magazine "The American Prospect", and has written many books on public policy, including the Pulitzer winning "The Social Transformation of American Medicine". Despite his academic background, however, he writes in a real world political framework, and has the experience to back it up -- he was a senior advisor to President Clinton during the 1993 attempt to reform healthcare. Clearly, he has a liberal back- ground, but his analysis focuses on facts.

The first half of the book surveys efforts to reform U.S. health care over the past hundred years. In so doing, it shows why the U.S. system has evolved so differently from that in most other wealthy democracies, where access to health care has long been treated as a basic right. There is a lot more to this difference than the "greedy health care interests" that progressives like me view as the problem. The interests are certainly greedy, but then so are most people and institutions, in most countries. In part, the U.S. situation reflects an individualistic national ethos, and in part a series of historical accidents. Starr's focus is not, however, on American exceptionalism, or on randomness.

Rather, his point is that efforts to reform health care in the US contributed to the development of a system that is extraordinarily hard to reform. Two of these were critical. First, in 1953, the IRS ruled that employer contributions to group health insurance policies were not taxable. That made health benefits an attractive way for companies to compete for labor, and employer-based insurance became the dominant form of health care provision in the U.S. This meant that a large portion of the population was reasonably well insured against medical costs -- they formed a "protected population" that did not face any personal need for improved access to medical care. Second, in 1965, President Johnson pushed through Medicare, and Medicaid. Like employer-based insurance, Medicare put many millions of people into a protected category.

These two events created a big protected population, creating what Starr calls a "policy trap". That is, as he describes it, "an increasingly costly and complicated system that has satisfied enough of the public and so enriched the health-care industry as to make change extraordinarily difficult." The first half of the book shows how we reached that policy trap.

The last section of the book, happily, is not nearly so relevant as it was when the book was published in October of 2011. That is because it dealt with the threats to Obamacare from the then-pending Supreme Court decision, and from the 2012 election. Those removed the threat of judicial overthrow or a post-election repeal. For this, many people should give thanks.

The second half shows how the Obama Administration succeeded in implementing a truly major reform of health care despite this trap -- and by the skin of its teeth. This half is much more fun that the first half, because most of the players are still very much with us, and because the events are just fading out of the headlines. Starr writes it like a political thriller, with lots of who did what to -- and for -- whom. This discussion, however, benefits enormously from the less entertaining first half of the book, which makes it clear why Obamacare was so hard to pass, and why it had to be more limited than many progressives would have liked.

In a penultimate section, Starr analyses the Affordable Care Act, treating it as a major but limited effort. Its key effects are to sharply reduce the percentage of the U.S. population that is uninsured, from 17% to an estimated 6%, and to improve protection for the middle class. But it does this mostly through changes in insurance, leaving the organization of medical care largely unchanged. It includes efforts to slow the growth of spending on health care, but does not assure that end.
Despite that, after reading Mr. Starr's book, I feel much more positive about Obamacare than I did. It may not be perfect, but -- given the obstacles to reform -- it is important and impressive.

For those who are interested in a more polished review, check out the NYT review at http://www.nytimes.com/2011/11/20/books/review/remedy-and-reaction-the-peculiar-.... ( )

In no other country has health care served as such a volatile flashpoint of ideological conflict. America has endured a century of rancorous debate on health insurance, and despite the passage of legislation in 2010, the battle is not yet over. This book is a history of how and why the United States became so stubbornly different in health care, presented by an expert with unsurpassed knowledge of the issues.
Tracing health-care reform from its beginnings to its current uncertain prospects, Paul Starr argues that the United States ensnared itself in a trap through policies that satisfied enough of the public and so enriched the health-care industry as to make the system difficult to change.
He reveals the inside story of the rise and fall of the Clinton health plan in the early 1990s—and of the Gingrich counterrevolution that followed. And he explains the curious tale of how Mitt Romney’s reforms in Massachusetts became a model for Democrats and then follows both the passage of those reforms under Obama and the explosive reaction they elicited from conservatives. Writing concisely and with an even hand, the author offers exactly what is needed as the debate continues—a penetrating account of how health care became such treacherous terrain in American politics.