Book Review

Health Care Politics

The Politics of Health Care Reform: Lessons from the past, prospects for the future

N Engl J Med 1995; 332:195January 19, 1995

Article

The Politics of Health Care Reform: Lessons from the past, prospects for the future
Edited by James A. Morone and Gary S. Belkin. 557 pp. Durham, N.C., Duke University Press, 1994. $19.95. ISBN: 0-8223-1489-4

This ambitious work helps explain why the American public should have expected the passage of health care reform legislation by the 103rd Congress and the Clinton administration. The book assesses health care politics in the United States, political institutions related to health care, the relation between business and health care, the relation between federal and state governments with respect to health care, and lessons from other countries that might apply to the United States. The authors knew as they prepared this book that passage of health care reform legislation was going to be difficult, and that the final shape of the health care package had not yet been determined, but they were confident that it would be adopted.

Some of the chapters are excellent, especially David McBride's ``Black America from Community Health Care to Crisis Medicine.'' Nevertheless, there is a striking disconnection between the thrust of the chapters and the end result of the recent legislative period. The question this work raises is whether it clearly explains why health care reform failed. The tone of the national debate over health care is very different from the notes sounded by the many authors of this work. These stark differences in emphasis may explain why health care reform was not successful, and why the American public felt so out of touch with leaders in academic medicine. Much of this book focuses on the rights America confers on individual members of society, and the public's expectation that these rights should be exercised with respect to health care needs. However, the language of the arguments is couched very much in the idioms of the great social programs of the 1960s. It is exactly this type of language and framework that the American public so unanimously rejected in the 1990s.

An example is Deborah Stone's chapter on the struggle for the soul of health insurance, which talks about mechanisms of risk classification in insurance programs as a means of perpetuating an economically segregated society. There may be many business and regulatory problems that influence the design of insurance programs and the development of risk pools, but that is not how Stone views the issue. Judging by the outcome of the health care debate, most Americans believe that these problems can be remedied through the private sector and that they do not require the wholesale adoption of new social interventions. It is also unclear whether the public agrees with Stone that public-sector programs are more virtuous than existing private-sector ones. It is equally telling that the authors quote heavily from the speeches of Senator Harris Wofford of Pennsylvania, an early advocate of health care reform and one of the casualties of the 1994 election.

The chapter on Congress in the 1990s uses the number of nonprofit groups as a measure of the influence of the private sector on Congress, yet the author fails to foresee the power garnered by individual political-action committees, such as the Health Insurance Association of America through its famed Harry and Louise advertisements. The author of the chapter does recognize, however, that health care reform as proposed by the Clinton administration offered a test of ``the proposition that the United States lacks the capacity to secure a major reorientation of its health care financing system.'' Chapters on popular support rely heavily on surveys of the general population as evidence of public approval for health care reform. Obviously, those attitudes were easily changed during the health care reform debate.

I think this book is very interesting. It may serve an important purpose in helping one to understand why the attempt to initiate health care reform was so unsuccessful. Clearly, the mainstream of social and political thought about the need for health care reform differs considerably from the dominant public attitude. It is revealing that our social-policy experts were unable to foresee the defeat of the health care reform movement and were incapable of predicting the rejection by the American public of many of the social premises underlying the programs outlined in this book. Political scientists and health policy makers may have to determine whether fundamental attitudes toward social programs in the United States have changed over the past 30 years. If this is the case, social policy makers will need to articulate their views in a language that is much more palatable in today's conservative political climate. The goals of the health policy program that underlie many of the chapters in this book are probably those of most Americans. The issue may simply be our inability to communicate these issues in an acceptable manner to the general public.

Kevin A. Schulman, M.D.
Georgetown University Medical Center, Washington, DC 20007