Health policy Woodstock (Journal of Health Politics, Policy, and Law on health reform)

The following is a guest post by Harold Pollack, the Helen Ross Professor of Social Service Administration at the University of Chicago.

Our shop at the University of Chicago School of Social Service Administration houses the Journal of Health Politics, Policy, and Law (JHPPL), edited by my hallway colleague Colleen Grogan.

Colleen has quarterbacked a special issue, Critical essays on Health Reform, which includes a Woodstock lineup of political scientists, public health scholars, sociologists, even the occasional economist: James Brasfield, Larry Brown, Andrea Campbell, Judy Feder, David Frankford, Daniel Gitterman, Marie Gottschalk, Scott Greer, Colleen Grogan, Michael Gusmano, Jacob Hacker, Mark Hall, Larry Jacobs, Peter Jacobson, Tim Jost, Rogan Kersh, Miriam Laugesen, Harold Luft, Ted Marmor, David Mechanic, Edward Miller, Kim Morgan, James Morone, Laura Napiewocki, Jonathan Oberlander, Kieke Okma, Tom Oliver, Mark Peterson, Mark Pauly, Harold Pollack, Jill Quadrano, Thomas Rice, Marc Rodwin, John Scott, Mike Sparer, Frank Thompson, Carolyn Tuohy, Leah Voigt, and Joe White.

My own essay focuses on the value of the Affordable Care Act to improve population health. TIE readers are already familiar with the line of research ranging from the RAND Health Insurance Experiment to the work of McWilliams and colleagues that informs my relative optimism based on the potential to address hypertension and to improve population cardiovascular health. Like many other contributors, I am most concerned about the politics of health reform, which tends to marginalize public health and prevention, despite broad, generalized agreement on the importance of such measures.

Mark Hall’s contribution on safety-net care picks up on similar themes, arguing,

If we stitch together insurance expansions with different and better safety-net programs for various components of the uninsured, a uniquely American tapestry could eventually emerge — one that, finally, will put us on par with peer nations in providing nearly everyone adequate access to at least a decent minimum of care.

For most of these essays, the main research and writing were done before the 2010 elections. To the writers’ credit, however, many focused on issues that will be critical for a successful reform: Administrative feasibility, the mechanics of state-federal relations, Congress’s willingness and ability to appropriate the required funds and to provide the kind of midcourse corrections necessitated by the implementation of any complex reform.

Many contributors to this volume are political scientists and law professors. I’ve learned much during the health reform debate about both the necessity and the difficulty of integrating the insights of such scholars with what might be labeled bread-and-butter policy analysis. I and many other participants in health reform—scholars, advocates, and policymakers—brought expertise in health economics, comparative effectiveness research, and public health. There remains a large gap between those of us who bring traditional expertise in health services research and those of us who bring expertise in the federal budget process, the legal craftsmanship of legislation, the mechanics of Congressional politics, ERISA, fiscal federalism, and the everyday public management challenges of Medicaid and Medicare.

Mark Peterson provides a fascinating analysis of a basic question: Why was the Obama administration able to enact near-universal coverage when Democratic presidents from Harry Truman to Bill Clinton could not? As Peterson puts things:

Over the coming months and years journalists and scholars will imbue the literature with rich inside accounts of the precarious interplay of decisions and personalities, taut and suspense-filled narratives of advances and retreats, tales of opportunities seized and squandered, images of egos inflated and bruised, and colorful explications of how — finally and historically — an imperfect victory was snatched from the almost inevitably closing jaws of defeat….

These will be important, captivating, and informative works. But the stage needs to be properly set. The inside story, all of the maneuvering and machinations, would not have mattered but for the uniqueness of the moment.

Ultimately, such inside baseball mattered less than one might imagine. Specific rhetoric and legislative tactics definitely made a difference, particularly the President and Nancy Pelosi’s decision to stick things out after the election of Scott Brown. Yet the variables that really mattered concerned the structure of our institutions and the uniquely favorable political and institutional environment Democrats enjoyed for the first two years of the Obama presidency. The most assertive and skilled presidential leadership would not have sufficed to pass the Affordable Care Act without a large, relatively cohesive House and Senate majority.

We now live in a different moment. Brown University political scientist James Morone notes:

[t]he final legislation is rich with long-sought Progressive goals — funding for public health initiatives, community health centers, electronic medical records, and much more. Despite their success, Democrats ran disastrous midterm election campaigns, weakly deflecting the debates away from the signature reform they had won after so long. The Democrats finally got their health policy, but once again — yet again — managed to lose the political debate.

Republican victories, for at least one election cycle, introduced yet another fundamental uncertainty into an already complex set of reforms.

This special issue won’t tell you how the story will turn out. It does provide an essential roadmap into what matters, and why.


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