Sociologist and healthcare policy expert Paul Starr, author of Remedy and Reaction: The Peculiar American Struggle over Health Care Reform, opened his talk on America’s seemingly endless healthcare war on a somber note. “The United States stands out in healthcare in several unhappy ways,” he began, pointing out high costs and a growing number of people without health insurance. “We’ve also been fighting over this issue for nearly a century. In no other western country are there such persistent, basic, bitter divisions over the question of whether there should be public responsibility for the cost of illness. Only in the United States do conservative parties equate public financing of healthcare with loss of freedom.”

For Starr, the only way to make sense of America’s peculiar relationship to healthcare is to explore its history: this was not a foregone conclusion. Although Americans like to use “American self-reliance” to explain their resistance to public healthcare, Americans are also egalitarian. “How is it that we never hear the phrase ‘socialized education?’” he asked, drawing laughs from a full house at the Skirball Center, at an event sponsored by the California HealthCare Foundation.

The healthcare industry has gotten rich off privatized care, and those Americans who are protected by current policies (what Starr called “the best-organized groups in society”) feel that they deserve their healthcare for moral reasons. They don’t want to be taxed for other groups who haven’t “earned” their healthcare. This attitude is “partly responsible for the bitter, vituperative aspect” of our healthcare politics, said Starr.

To illustrate the history of America’s healthcare wars, Starr likened the conflict to a play in three acts, which continues today.

Act One begins in the post-World War I era, when the first proposals for a government healthcare program in the U.S.–to be instituted at the state level–were modeled on well-established European systems, and Germany’s in particular. Opponents called this “a plot by the Kaiser” and succeeded in defeating it across the country, including in New York, where Franklin Roosevelt was governor. He’d put healthcare reform on the back burner as a result. And once the Cold War began, government-run healthcare was equated with Soviet socialist policy thanks to a script that the American Medical Association and other groups had developed over time.

In Act Two, Lyndon B. Johnson passed the 1965 Social Security Act to establish Medicare in the hope that it would be the first step to a universal health insurance system. But the high cost of both programs (thanks to steep concessions) made them an obstacle rather than a boost. And though Richard Nixon and John F. Kennedy both had healthcare plans–Nixon’s in 1974 was in fact to the left of both Bill Clinton and Barack Obama’s plans–Watergate (and a scandal involving a stripper and Congressman Wilbur Mills, one of the architects of Johnson’s plan) ultimately meant failure.

Act Three, said Starr, is “the escape from the health policy trap”–perhaps. In the 1980s and early 1990s, healthcare costs were increasing more quickly than earnings. Americans could agree that the current healthcare system wasn’t working, but there was no consensus about a solution. Bill Clinton’s plan (on which Starr advised) “began with a lot of optimism, energy, and belief that something was going to happen” before devolving into divisions between Democrats and Republicans and within the Democratic party itself. When the Republicans who had offered cooperation withdrew their support to unite against Clinton, the plan was dead–and then 1994 saw Newt Gingrich take power in Congress. (“When I wrote the book, I thought was writing about a historical figure,” Starr quipped.)

Why did Obama succeed where Clinton failed? The answer lies in what Starr called “minimally invasive reform.” Healthcare reformists concluded that any legislation that could possibly pass would need to solve the most urgent problems of the uninsured and eventually control costs–but it couldn’t disturb people who were employed and had good insurance or conflict with the major interest groups.

Ironically, it was the right who led the way. In Massachusetts, Mitt Romney passed a plan (designed by the Heritage Foundation) that relied on a health insurance exchange with subsidies for private insurance and an individual mandate. In the Democratic primaries in 2007 and 2008, Hilary Clinton, John Edwards, and Barack Obama all put forth proposals following Romney’s framework.

By 2009 and 2010, the people leading the effort to get Obama’s legislation passed had the battles of 1993 and 1994 under their belts. “They had become both more cautious and more determined,” said Starr–as well as willing to make many more concessions. And the top leadership in Congress was determined, too, to pass the bill.

“It’s a miracle that they were able to get all 60 [Democrats] when they had 60, in order to pass it in December of 2009,” said Starr. Although he has criticisms of the bill, he was clear that its passage was above all “an achievement … given the long history that preceded it and all of the obstacles that stood in its way.” This is the most important legislation in decades for improving the lives of low-wage Americans, he said.

Starr didn’t hesitate to point out the bill’s problems: the four-year lag between passage and implementation in 2014; the individual mandate, which is the focus of legal challenges and political opposition; and the fact that “the bill is unloved by Democrats because it doesn’t live up to their expectations, and hated by Republicans.” If the bill fails, said Starr, our healthcare war will continue–and the search for remedy will resume under a cloud of uncertainty.

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Read expert opinions on why America’s healthcare reform wars are so bitter here.

*Photos by Aaron Salcido.