• Inside health reform

    As you can no doubt tell from my recent posts, I found a lot to like in John McDonough’s Inside National Health Reform.* I’ve now read the whole thing.

    It’s really two books in one. The first is the story of the politics of getting to reform. The second is the story of the law itself, what it says and what it means. I’ll bet you’re thinking the first part is (political) mind candy, the second spinach. You’re half right. McDonough was (is) a true insider, having served as senior adviser to the Senate Committee on Health, Education, Labor and Pensions, which granted him access to many crucial meetings and key individuals. He put his inside knowledge to use in the first part of the book, where you’ll find many of the quotes I posted while reading (see the INHR tagged posts).

    The second part, which explains the actual law, surprised me. I expected a dry recounting of the gist of titles, subsections, amendments, etc. That would be boring. I expected I’d skip most of it, since I’ve read the law and summaries of it already. But that’s not what McDonough did. Well, yes, he did recount what the law says, but he broke it up with long passages explaining how key portions of the bill came together politically and how they fit into the context of the US health system.

    It was a brilliant idea, to interleave bits of spinach with shots of sugar. It worked. (Indiana State Fare food vendors, take note!)

    If I taught a course on US health policy I’d include INHR as required reading. I’d pair it with Paul Starr’s Remedy and Reaction (forthcoming, follow the link to another for pre-ordering). The latter, as I wrote, describes the US health policy trap–that most voters (most workers, nearly all the elderly) cling tightly to the health care benefits they have, constraining the politically feasible set of reforms.

    Though there is considerable overlap, Starr’s focus leans more toward health care policy and McDonough’s toward health care politics. If Starr’s policy trap is a box or room, McDonough enters it and describes how it’s built, the nature of the bricks and mortar walls. How exactly do the impulses of voters, their staus quo bias, play out within and in service to the politics of interest groups? More than that, how did those interest groups position themselves within the dynamical legislative process and with respect to each other? From his inside view, McDonough explains.

    McDonough begins the concluding chapter,

    There was a better national health reform law to be written than the Affordable Care Act. There were better approaches to save money and to restrain the rising costs of health care, better ways to cover uninsured Americans, better methods to improve the quality of medical care and to put the nation on a healthier path, and smarter ways to pay for the whole effort. It is fair to say that the ACA is no American’s idea of the best possible reform. And yet–because Americans do not agree at all on what the best possible reform would be–the ACA is close to the best reform that could be achieved in the 111th Congress and close to the best reform achievable at least since 1993-94.

    This is correct. In the 111th Congress, it was the ACA or no comprehensive reform. If you don’t agree, read McDonough’s book. It may not convince you, but it will certainly provide a lot of evidence you’d need to address to make a strong counter-argument.

    * Full disclosure: I received a courtesy copy of INHR from the publisher.

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    • Did we get a second-best solution (the ACA) because “Americans do not agree” or because private insurers control the terms of debate and weren’t about to allow a discussion of single-payer? Obama, though on record as favoring single-payer, foreclosed on that option before the debate even started. Whether this was cowardice or pragmatism, the most worrisome aspect of the whole reform debate is the way corporate interests, more than the “impulses of voters,” determined its parameters.