Styx guitarist James Young wrote this song and sang lead vocals. He wrote it about his wife, Susie, who suffered from a rare, incurable condition called porphyria. It's a love song, but not a typical one, as Young delivers a snarling lyric with lines like, "Does that smile seem to wear you down."
She is his "Miss America," and he is singing about her struggle, most overtly in the line, "This dream that you must live, a disease for which there is no cure."
The chorus ends with the band singing "our love," affirming the tribute.
This song is often interpreted as a gritty send-up of the Miss America pageant, taking aim at the shallow and exploitive production that casts aside the winner as soon as someone new takes her crown. While the pageant does frame the metaphor, it is not what the song is about.
James Young was sometimes cast as a misogynist for his work on this song, thanks largely to the Rolling Stone review of The Grand Illusion, in which Joe Fernbacher wrote: "'Miss America' simply reeks of misogynistic misdirection. What Styx thinks is a compliance with current feminist fashion turns out to be nothing more than a spiteful acquiescence to sexual bigotry and impotence."
Dennis DeYoung responded on his website: "It's his ignorant and malicious evaluation of the song's lyrical content that enrages... I witnessed first hand the agony and feeling of helplessness he [James Young] endured."
The keyboard figure is a riff on "There She Is, Miss America," the song host Bert Parks would sing to the winner of the Miss America pageant.