Sisyphus gets to the top: how America's forbidding political landscape made health care reform impossible for Clinton and nearly so for Obama.

• Author: Pollack, Harold

Remedy and Reaction: The Peculiar American Struggle over Health Care Reform

by Paul Starr

Yale University Press, 336 pp.

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No other nation organizes its government as incoherently as the United States.... Its policies are set to run a legislative obstacle race that leaves most reforms sprawling hopelessly in a scrum of competing interests. Those which limp into law may collapse exhausted, too enfeebled to struggle through the legislative tangle which now confronts them, and too damaged to attack the problems for which they were designed. The humiliation of the will of government is popularly reckoned no bad thing.

Thus begins Peter Marris and Martin Rein's landmark 1967 book, Dilemmas of Social Reform: Poverty and Community Action in the United States. Their critique of the structural impediments of American government could easily have been written today by some liberal blogger lamenting the shortcomings of health reform. It is certainly a theme of Paul Starr's new book, Remedy and Reaction: The Peculiar American Struggle over Health Care Reform. A Princeton professor and Pulitzer Prize-winning author, Start was a senior adviser to President Bill Clinton during the 1993 battle over health care reform. While he is an ardent liberal and a supporter of the 2010 health bill, Start has maintained a critical distance from the Obama camp. This unsentimental perspective serves him well in this outstanding volume.

Remedy and Reaction accomplishes several tasks in its brisk 300 pages. The first quarter of the book provides a tour de force 100-year history of American health care reform--a dimension often missing from current policy discussion. Encountering many useful nuggets of information along the way, one finds the need to revise many commonly accepted accounts of how we came to our present predicament.

You may have heard, for instance, that employer-based coverage was created during World War II to evade wage and price control--and, certainly, that history matters. Yet, as Starr relates, employer-based coverage started in earnest during the 1930s, as early Blue Cross plans addressed classic market failures in the provision of health coverage. Providing health insurance through large employers offered economies of scale and provided stable and favorable risk pools, mitigating the problems that perennially plagued insurance markets. Given this history, it's important to keep in mind that any hasty effort to unravel employer-based coverage--such as candidate McCain's 2008 plan--might prove quite harmful if these concerns were not addressed.

It's common knowledge that, in signing the Affordable Care Act, President Obama succeeded at a task that had eluded his predecessors going all the way back to Theodore Roosevelt. Indeed, many presidents have sought to expand health services while in office, but, as Starr notes, only one previous president entered office with an explicit promise to provide near-universal health coverage through health care reform: Clinton, in 1993.

From his insider's perspective, Start describes the painful failures of the Clinton reform effort. Many liberals--not least many Obamans--blame one or both Clintons for the debacle: had they presented a bolder and simpler plan, had they shown more tactical savvy, had they dealt more effectively with key House and Senate leaders, had Daniel...