Book Review

Governing Health: The politics of health policy

N Engl J Med 1997; 336:1034April 3, 1997

Article

Governing Health: The politics of health policy
By Carol S. Weissert and William G. Weissert. 361 pp. Baltimore, Johns Hopkins University Press, 1996. $24.95. ISBN: 0-8018-5266-8

There are riveting books about politics and books about riveting politics. The Weisserts have created a competent example of the latter type, concentrating their attention on the way in which the American political system — and especially its national institutions — deals with issues in the varied world of medical care.

The work is a useful textbook for those in medical care with only passing knowledge of the patterns of federal policy making in the postwar period. It is as if the Weisserts set out to write a textbook on American politics, but almost exclusively used examples of controversies in medicine. So, for instance, part 1 has separate chapters on Congress, the presidency, interest groups, and the bureaucracy — standard ingredients of conventional textbooks for college students. (Indeed, the authors suggest that they wrote the book partly out of frustration at being unable to find “a text written by political scientists for use in health politics classes.”) Understood this way, the book serves the textbook audience well, employing a wide range of research on American political institutions to characterize recent trends and present practice, largely in Washington, D.C.

The second part of the book concentrates on what the authors call the “policy process.” They review a number of competing methods of characterizing the ways in which public policies do and do not get made in the United States. The Weisserts concentrate their attention on the long battle over universal health insurance, the origins and development of Medicare and Medicaid, and a few other striking controversies. They supplement these illustrations with brief characterizations of competing ways in which political analysts have categorized policy disputes in health and other fields. So, for instance, they pay considerable attention to the distinctions Theodore Lowi made with respect to distributive, regulatory, and redistributive policy conflicts. Other policy categorizations — from Lindblom, Kingdon, and others — are but briefly sketched. And there is an extended discussion of the rise and fall of health care reform in the early 1990s, one that relies largely on secondary journalistic materials and does not come to grips with the considerable amount of scholarly work that has already been published.

The result of all this is a book of solid research and uneven appeal. The textbook commentary on political institutions will be useful to the uninitiated and helpful to those whose experience is intermittent and limited in scope. The discussion of policy making makes no intellectual advances but conveniently groups together several approaches to understanding why American political institutions produce the policy products they do. This kind of scholarship, however, will not clarify many of the most compelling puzzles of recent years in the world of American medical care. It barely mentions AIDS or the more than decade-long dispute over the politics of tainted blood and the devastated hemophilia community. It passes quickly over disputes about the role and performance of the Food and Drug Administration and gives the reader little help in understanding issues as diverse as euthanasia and alternative medicine, rationing, and the rational allocation of funds for medical research. The reader is left with neither a map of the varied types of conflicts in medical care nor a guide to what those conflicts might look like in the near future. In short, this is a textbook on American politics and health topics that is struggling without success to be a book about the fascinating and frustratingly diverse politics of health care in America.

Theodore R. Marmor, Ph.D.
Yale University School of Management, New Haven, CT 06511