Book Review

Experiencing Politics: A Legislator's Stories of Government and Health Care

N Engl J Med 2001; 344:1483May 10, 2001

Article

Experiencing Politics: A Legislator's Stories of Government and Health Care
By John E. McDonough. 342 pp., illustrated. Berkeley, University of California Press, 2000. $50 (cloth); $19.95 (paper). ISBN: 0-520-22410-8 (cloth); 0-520-22411-6 (paper).

John McDonough's Experiencing Politics is a brilliant book. McDonough provides a fascinating account of the high stakes, the drama, and the excitement involved in making laws. This is an enlightening and entertaining book that offers an inside, real-life look at legislating. McDonough's book seamlessly blends academic political science with lively “case stories” drawn from his 13 years in the Massachusetts legislature. His book will interest not only academics but also citizens engaged in the political process, especially those concerned with health policy. McDonough holds a doctorate in public health from the University of Michigan, and he specialized in health policy during much of his legislative career. That special interest is reflected throughout the book.

Perhaps a disclaimer is in order. John McDonough is a good friend of mine, and I have often turned to him for advice on health policy issues. His counsel was always valuable. The qualities that make him a valued advisor — a clear understanding of the links between politics and policy, an instinct for what is achievable, a shrewd grasp of strategy and tactics, a sound understanding of the substance of health policy, and a passionate commitment to improving society — are very much in evidence in this book.

McDonough uses a number of concepts from academic political science to explain how policy evolves. He discusses the use of language in politics, both as a barrier and an aid to reaching agreement and as a tactical weapon that can determine the outcome of a conflict. He describes the ways in which the scope, site, and intensity of a political conflict can shape its outcome and the ways in which participants in a political conflict may try to manipulate these factors to achieve their own goals. He explains how the positions taken by elected officials are shaped not only by their need to represent their constituencies but also by a web of relationships that can be even more important in defining the resulting policies. He explains the factors that determine whether incremental or comprehensive reform is achievable.

McDonough is a lively writer. The detailed descriptions of the fights over policy in which he has been involved are well worth the price of the book. One of the most interesting and important events McDonough describes is the effort to enact a children's health insurance program funded by increases in the cigarette tax — a policy prescription I was later able to follow successfully in Washington.

McDonough explains how a combination of the mobilization of citizens, changes in political discourse, focused policy research, and a proposal that brought together advocates for children and senior citizens, proponents of expanded health insurance coverage, and antismoking forces made it possible to enact an important policy initiative that has made a real difference in the lives of tens of thousands of Massachusetts children. The achievement was even more remarkable because it required the override of a gubernatorial veto and the defeat of a well-funded opposition effort by the tobacco companies.

Other cases are equally compelling. McDonough discusses policy issues ranging from rent control, to attempts to deal with an urban gang that was impeding neighborhood redevelopment, to the demise of hospital rate setting, to the death penalty. The book includes portraits of the compelling figures, ranging from a charismatic urban priest to the Speaker of the Massachusetts House, who made a difference in the outcome of these policy debates.

McDonough's book is more than a scholarly dissection of what happens and why. It is a call to action and a guidebook for every citizen who cares about public policy and wants to have an effect on people's lives. His compassion for all Americans — a trait that has characterized McDonough throughout his career — comes through clearly in this important book. As McDonough says in his introduction, “Politics is about `us,' about the needs of ordinary people and how they get translated effectively or poorly into policies. . . . My challenge and hope are to help readers become more familiar and comfortable with life in the arena so that you will want to join.” Any reader with an interest in politics and policy will benefit from reading this remarkable book.

Edward M. Kennedy
U.S. Senate, Washington, DC 20510