< In Sickness and In Health


Friday, August 21, 2009

For historical precedent on health care reform, what first springs to mind, of course, is the Clinton administration fiasco in 1993 and '94, but using the Clintons’ experience as an object lesson doesn't really tell the whole story. Attempts at a national health care program are almost a century old, says Princeton professor Paul Starr, author of the book, The Social Transformation of American Medicine. And for as long as the idea has been popular among incoming administrations, it has been vilified, and successfully derailed, by critics. Starr knows this firsthand, because in addition to being an author and a professor of sociology and public affairs at Princeton, he was drafted by the Clinton White House to help avoid the mistakes of the past. He joins us now. Paul, welcome back to the show.

PAUL STARR: Glad to be with you, Bob.

BOB GARFIELD: I want to start with where Brooks Jackson left off, and that is the Truman administration and a very successful effort by the American Medical Association to demonize any federal involvement as socialism. Can you take us back?

PAUL STARR: The issue of health insurance had first been raised before the First World War and was then defeated, partly because it was actually associated at that point with Germany. And when war broke out with Germany it helped to sink that proposal. Then in the late '40s, which is, of course, when the Cold War was beginning, the opponents associated national health insurance, as it had come to be called, with Soviet-style socialism.

BOB GARFIELD: What exactly did the AMA and its PR people do to create the notion that a national health care plan was somehow Bolshevism?

PAUL STARR: They suggested that Lenin had supposedly [LAUGHS] said that health care was the first step toward instituting Communism. There was a mythical quote that no one has been ever able to discover [LAUGHS] to that effect. And they argued that it was, you know, like a gateway drug and the beginning of a slippery slope toward government control of everything. In that period, given the Cold War, that argument was a powerful one.

BOB GARFIELD: Maybe the Lenin quote is somewhere in the House bill next to the death panels provision.

PAUL STARR: Page 764.

BOB GARFIELD: [LAUGHS] Now, before Truman there was Roosevelt, Franklin Delano Roosevelt, who himself had battles with the AMA. What was the nature of those?

PAUL STARR: Roosevelt never took on the AMA, directly. The Committee for Economic Security, which recommended the old age insurance system that we know of as Social Security, they also recommended health insurance. But when Roosevelt had to decide what was he going to submit to Congress in 1935, he held back the health insurance provisions. He was afraid of the AMA’s opposition, and so, decided to leave it to a later day. But during the Great Depression, Franklin Roosevelt and the American people had a lot of other things to worry about, and so he never got back to health insurance, and it was only Harry Truman who then was the first president to make national health insurance a cause.

BOB GARFIELD: It would have fit very snugly within the New Deal, but you’re suggesting that FDR simply knew that he would not have the AMA on board and he needed them for other initiatives.

PAUL STARR: Well, he needed to pass Social Security, which was not an easy thing to do in 1935. And, by the way, the opponents of Social Security also said it was socialism.

BOB GARFIELD: So, if we can assume for just a moment that the President is right and the Clintons were right and Harry Truman was right and Teddy Roosevelt [LAUGHS] was right, that the government should be intervening in the health care system to keep down costs and create something close to universal coverage, what is it that the AMA in the '40s and '50s and the health insurance lobby in the '90s and the current ideological opponents in 2009 have been able to consistently do to obliterate the common sense of health care reform?

PAUL STARR: They've been able to raise fears among the House that they will lose from reform. And America has a system that does provide protection to a lot of people. And yet, we all know that health care costs are rising, they're staggeringly high, and I think as a result even the haves are nervous about losing what they've got. And so, consequently, I think they can be mobilized against reform. The single biggest surprise this year is that the major health care interest groups have not been a factor in the mobilization against reform. It wasn't the AMA. It hasn't been the pharmaceutical industry. It hasn't been the hospitals. By and large, they've negotiated in many cases, a pretty good deal for themselves. So it is an ideological and political opposition this time, almost purely. And here I think history is really exercising a very powerful effect, because the last time we fought this out, back in 1993-'94, the Republicans won, and so I think they are trying to reenact history. They are trying to do to Obama what they did to Clinton, not just to defeat the health care reform but to neutralize his entire agenda.

BOB GARFIELD: Well, Paul, as always, thank you very much for joining us.

PAUL STARR: Okay, thank you.

BOB GARFIELD: Paul Starr is a professor of sociology and public affairs at Princeton University and author of The Social Transformation of American Medicine.

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