In Remedy and Reaction, Professor Paul Starr puts the Patient Protection and Affordable Care Act (PPACA) and earlier efforts to achieve universal health coverage into historical and political context. Starr points out that “in any given year, the most costly 5 percent of people account for more than 50 percent of health-care costs, and the top 10 percent of people account for 70 percent of costs (p152).” These numbers make it clear that a mandate of some sort (forcing either the individual or the employer to pay for health insurance) is necessary to ensure the viability of any plan that attempts to provide universal health coverage. Without such a mandate, healthy people are not likely to pay for health care. As healthy individuals eschew coverage, the same coverage gets more and more expensive to cover an increasingly sick and needy subscriber population, a phenomenon known as “adverse selection.” One way to prevent adverse selection is to promote the formation of groups, or alliances, for purchasing insurance that will spread the associated risk and make premiums more affordable.
Adverse selection has garnered extensive political attention. It served as the driver behind the Clinton proposal to create “regional health alliances,” and it prompted the individual mandate in the 2007 Massachusetts health care plan shepherded into law by then Gov. Mitt Romney (who as a Republican presidential candidate now disavows the mandate). Newt Gingrich’s “Contract with America” in 1994 helped shift the focus of health care reform from universal coverage to cost containment in an effort to create a balanced budget. Throughout the book, Dr. Starr explores numerous political approaches to adverse selection and examines the respective effectiveness and validity of the various approaches.
Material in the book is organized chronologically, beginning with the first mention of “social insurance” and “protection against the costs of sickness” in the 1912 presidential election by the Progressive Party. The text touches on relevant historical predecessors of the PPACA such as a failed 1943 bill that proposed comprehensive health insurance and the emergence of employer-based health insurance after World War II. In 1974, Richard Nixon proposed comprehensive health insurance that relied on an employer mandate, but the Watergate scandal ended the effort. Dr. Star, who was an advisor to Hillary Clinton’s Health Policy Task Force, then proceeds to devote almost a quarter of the book to the Clinton administration and its impact on health care policy. The author is sympathetic to the Clintons but critical of the way they introduced their policy and of the media, and the book is valuable for its insider’s analysis of the political factors that led to the failure of the Clinton health plan. The book ultimately concludes with chapters on the Massachusetts plan, the presidential election of 2008, and the success of the Obama administration in effecting passage of PPACA in 2010. Although occasionally dense, Remedy and Reaction is generally quite readable for the non-expert. It would be of greatest interest, though, to historians and health care policy analysts. If, however, the U.S. Supreme Court finds the individual mandate to be unconstitutional, then politicians and lobbyists on both sides of the debate will be scouring the book for insights and strategies for the next battle over comprehensive health coverage.