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The Politics of Medicare: Second Edition (Social Institutions and Social Change)

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Have you ever wondered how Medicare-the federal health insurance program for the elderly and some disabled--became such a hot news topic, or why its administration and benefit package (the lack of outpatient drug coverage, for example) seems so inexplicable and byzantine?

If so, Theodore Marmor's reissue and revision of The Politics of Medicare is the book you want to pick up. There is no comparable book of its kind. Other scholars have studied Medicare's origins. Journalists trace the ebb and flow of contemporary Washington battles over Social Security and Medicare. But Marmor, a Yale professor and health policy guru, has written the definitive analysis of how the political battles waged over health insurance and Medicare from the 1940s onward powerfully shape the debate over the program to this day.

Wondering why Medicare, unlike almost all major private insurance plans, fails to cover most prescription drugs? The seeds of an answer may be found in the fears of 1960s legislators that the unpredictable cost of drugs could swamp the program at its outset. Unsure why medical expenditures took off in the 1960s and 1970s? Partly because doctors, who had led the charge against a government-sponsored social insurance program for the aged, benefited enormously from generous rules that were designed to assauge their fears about participation. Puzzled how Medicare became such a political hot potato after years of uninterrupted popularity? Marmor deftly shows how the Reagan administration reoriented widely-held fears about medical inflation into narrower fears about the supposedly unsustainable cost of public programs.

Another reason that this astute volume bears reading, or rereading: Marmor shows that elections can really matter. In the absence of the Democratic majority in Congress that emerged from the 1964 elections, passage of Medicare would have been delayed or forestalled altogether.

Within the cozy world of health policy analysts, Marmor is known for being a staunch proponent of national health insurance and a skeptic about the potential of HMOs and different forms of "managed competition" to control health costs and delivery quality care. His convictions enliven the text rather than detracting from its rigorous logic. This is a book that anyone interested in the politics of health care, and in American politics in general, will appreciate.

One thing alone mars this otherwise impressive book: its packaging. Sadly, any seven-year old with access to Microsoft Excel could have improved on the volume's rudimentary and unappealing charts and graphics. But the reader shouldn't let this superficial flaw detract from Marmor's important and unusually well-written book.

Revised for the first time since 1973, Marmor's *The Politics of Medicare* still stands as the best single book on the political genesis of Medicare. In this valuable new edition, Marmor brings his classic analysis up to date while addressing the arguments of contemporary critics of the program. During an election year in which Medicare looms large, there is no better guide to the political past and future of America's public health insurance program for the elderly and disabled.

I have read two reviews of this book in odd places, both of which are highly favorable. According to John Glasel of the Musician's Union in NYC, Professor Marmor's 'perceptive work analyzes the partisan squabbling that hs shaped Medicare over the years. The first part, a reprint of the first edition of this book, traces the history of the fight for government health insurance from the 1930s to the passage of Medicare in l965. The book's second part, completely new in this edition, brings the history up to date. Many scholars, according to Glasel, have long considered the first edition of this book the "definitive work on the subject. Its new edition should now be accorded that distinction." I agree with that judgement very much. So does Jeff Levine of WebMD's Washington Bureau, who described The Politics of Medicare as "a book for serious students of public policy," one which does not simply recite "historical facts" but analyzes the origins of Medicare and then, in a complex and thoughtful way, tells the story from l965 to l999.

The first edition of The Politics of Medicare, reprinted in part for the second edition, provides an engaging analytical structure for understanding the complex forces of governments and politics. While studying under the author, a gifted political scientist, years ago, the first edition was a cornerstone in our studies of healthcare politics and programs in the United States. The book equips the reader with the tools and knowledge to understand political forces well beyond the Medicare program.

The analysis of Medicare in the 1990s, found in the current volume, is excellent. This is an ideal time to read or reread the book since Medicare program changes will face our new President and the newly elected or reelected members of our House of Representatives and Senate during 2001. This fall I read the second edition and found the book very informative and enjoyable.

As we enter another Presidential Political campaign, where the issues of saving Medicare, Medicaid, and Social Security will be hotly debated, this is an important book that documents the history of the Medicare program from the 1930's to the ultimate passage of the program in 1965. Professor Marmor is uniquely qualified to bring life to the events. It should be read by all who will want to understand how we "got where we are", and perhaps give insight to ways to make these important social programs more vibrant in the 21 st century

Theodore R. Marmor's book, The Politics of Medicare, 1970, second edition, 2000, is in some ways complementary to Jonathan Oberlander's book, The Political Life of Medicare, 2003. Prof. Marmor, at Yale, supervised the graduate studies of Prof. Oberlander of the University of North Carolina. The Marmor book gives a briefer treatment of the political disputes over Medicare during the 1980s and 1990s but a fuller treatment of the development and enactment of Medicare.

Both books consider the Clinton administration's attempt at health care reform in 1993 and 1994 and the Medicare cuts in the Balanced Budget Act of 1997. Both stop short of prescription drug coverage in 2003 and Congressional postponements of Medicare cuts in 2003 through 2008 (once each), 2009 (twice) and 2010 (once so far). Neither book analyzes the arbitrary structure of the cuts nor predicts their postponement.

Prof. Marmor explains Medicare, in comparison with other national health-care programs, through determination to structure earned benefits rather than social welfare: limited to people aged 65 and over but without a means test and financed by regressive payroll taxes. He shows how critical features such as lack of cost controls were political adaptations. The primary architects, Rep. Wilbur Mills and Wilbur Cohen, later HEW Secretary, believed that use of payroll taxes rather than general revenue would counter inflationary pressures. Perhaps they did over some years, but Prof. Marmor shows that hospital charges, already rising rapidly, quickly took an even steeper course (Figure 6.1).

Of interest in the aftermath of 2010 health-care reform is Prof. Marmor's picture of the months after Medicare enactment. He shows opponents failed to sustain their focus. Medical professionals became absorbed in details of organizing the program. That is unlikely to be the pattern for 2010, when implementation of care was largely delayed four years. Once again the structure of a health-care program was dominated by politics: the delay was critical to lower costs in early years, a concern without parallel in Medicare. Medical professionals became deeply concerned over pending cuts in payments, also without parallel. Political potentials following enactment of 2010 health-care reform therefore differ substantially from those in 1965.

Other comparisons are noted by Don Wolfensberger, Health care reform and the Medicare analogy, Woodrow Wilson Center, September, 2009, at [...] Profs. Marmor and Oberlander also published an outline of recent prospects for health-care reform [Health reform: the fateful moment, New York Review, August, 2009, at [...]]. Perhaps after the many controversies over 2010 health-care reform settle, Prof. Marmor will write a sequel to his 1970 book, taking advantage of his deep knowledge about how Medicare developed and evolved.