Book Two, Chapter Three: The Liberal Years

This chapter begins to foreshadow many of the issues we still struggle with in health policy today and also shares some eerie similarities with today's political climate. What I found most interesting was the evolving federal role and the tie to leadership and the persistence of some inequities in health care provision that unfortunately persist today.

Starr notes, on page 349, that the Hill-Burton law "carefully limited political, particularly federal, discretion." This limitation of top-down authority is a trend we still observe today. For example, many economic development projects focus on similar geographic areas to the Hill-Burton act (at least in intent). Policy makers seem fervent that these projects should be bottom up efforts, or at the least, state to local, rather than federal-local. While some aspects of a centralized government are necessary in democracy, more than almost any other country, America has rejected the idea of paternalism from the federal government. In this light, it is particularly interesting to note the positive role the federal government has in driving the research agenda. It will be interesting to observe the changes, for example, in research with the Obama administration, as well as a Democratic Congress. Like the U.S. Congress of the liberal years, research grants are expected to rise.

I found it particularly of note that the inequities we struggle with today have been perpetual struggles, through various iterations of our health care system. Even with the best of intentions, the rural areas still end up with the fewest resources, the lowest paid (which likely translates into the least talented) staff and the most basic health care. Similarly, rural health centers face health problems far more complex than suburban health care institutions. Like the center in Mississippi, before providers could deal with sickness, they had to deal with the basic need of food. It is things like this that make working in a rural health center incredibly challenging and explains the high level of burnout.

Finally, the statement about Kennedy being a harbinger of change brings hope. Although we will never know what he would have done had he not been assassinated, his words ring remarkably close to that of President-elect Obama. The words of journalist Godfrey Hodgson offer a warning, however, that Americans "wanted change, but they did not want to be changed". (364) Thus, it is with that warning that we look forward to what Obama might change in health care.