Paul Starr (1) (1949–)

To the casual observer, a quick look at the American healthcare system brings out more questions than insights. Most of the developed world has some form of socialized medicine, whether nationalized health insurance or a national health system. By comparison, the American system appears disorderly and inefficient, yet resisting any changes, some swear by its effectiveness. Why? The answer lies not in a simple social, political, or economic force but in the scope of history. In this book, show more originally written in 1982, Paul Starr offers a seminal historical narrative that won the 1984 Pulitzer Prize. These dynamics remained relevant entering the Obamacare debates of the 21st century and continue to influence after that legislation modified the system.

I did not read the updated edition with a new epilogue published in 2017, but I am now curious what the epilogue says. This book clearly has the marks of a text that interested parties need to study for generations. It’s well-researched, eloquent, and with abundant endnotes. If anything, it’s too careful in its treatment and could become difficult and dense to read. Of course, readers who, like myself, appreciate scholarly erudition will appreciate the challenge.

America’s political landscape in the 1980s clearly influences Starr’s perspective. The 1960s offered ambitious scientific progress while the 1970s offered inflationary pressures. The election of 1980 transformed political dynamics by pushing cost controls to the fore. Starr’s final two chapters address these issues squarely to its original audience. However, the preceding nine chapters of history remain relevant and authoritative forty years later.

I slogged through years of medical school and presently work in medical research. Still, Starr taught me tones, and I wish I had read this book before I undertook these ventures. Understanding the social and economic dynamics can help explain human behavior around the biology and medicine. It simply isn’t better expressed than here. Other books offer more recent opinions about how to shape today’s future in 2024, but this history offers a clear explanation of how we got here. Again, reading forty years later, I found little that speaks of cobwebs in an ancient relic. It remains extremely relevant.

Anyone interested in a “big picture” look at the American medical system should start here. Political diatribes – and there are plenty of those – seem to paralyze rather than enhance constructive dialogue. This book, in contrast, informs and educates. Those working in the healthcare system and especially those leading the system can benefit. Those interested in government, politics, and health policy can also learn. I can see why it won a Pulitzer. Despite being rooted in discussions of the times, this book approaches being a timeless classic of a history about American healthcare. show less

Starr's book is one of the landmarks in the history of medicine. Using a framing theory of professional authority and a desire for independence, he examines medicine in America from the late Colonial period up through 1980. This book is sometimes overwhelming, but rarely obscure, and useful for both scholars and interested laymen. Starr explains the major periods of American medicine (disorder and disrepute to about 1870, standardization and professionalization from 1870 to WW2, and show more specialization and conglomeration after WW2) and their broader social and political contexts in education, public health, hospitals, and how doctors are paid.

Obviously, this book doesn't cover the past 30 years, and Starr is interested more in the character of a defined era than the actual moments of transformation, which to be fair, may be too elusive to really observe in a historic sense. But for anyone interested in why American healthcare is so expensive and why it is so resistant to reform, this is a definitive history. show less

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 show more 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-.... show less

I was at Drs. Glen and Ros Ramsey's house in 1982 or 1983 and Glen recommended that I read this book. Well, I thought it over and decided to go ahead and read it. Sadly, it is now a little dated, but I can't blame Glen for that, and it is a great socio-economic history of Medicine in the US–perhaps the greatest. The big villain is usually the AMA in most of the described conflicts over the years; this comes as no surprise if you realize what the AMA members' interests are. I am tempted to show more quote a great American, "Who knew that health care was so complicated?", but that's the one thing that (almost) everybody does know. The solution is easy, invite some Canadians down to set things up, but that would require either a benevolent dictatorship or a special freeze device that could be used to temporarily inactivate the AMA, big Pharma, the commercial insurance industry, the Blues, the hospitals, the medical schools, and all healthcare workers. They'd be pissed off when they thawed out, but, let's face it, they had their chance. show less