on October 18, 2011
The authors manage to make readers feel like they are sitting in on key high level meetings on health care reform- whether with key senators, President Nixon or President Clinton. It is mind boggling that these efforts spanned multiple presidencies, and that Stuart Altman has been working on many of these efforts for all of these years. Altman and Shactman take us on remarkable journey of health reform, leading into the somewhat improbable passage of health reform in 2010. Despite the extraordinary amount of fascinating details, this book is eminently approachable and highly readable-- more like a novel than a dry policy text. Anyone interested in understanding how the many subtle and not so subtle competing forces derailed past attempts at health reform will be interested in this book. Those of you interested in feeling like you've wrangled front row seats to one of the most vexing public policy and political questions of the past forty years will also find tremendous value in this book. Highly recommended.
on July 3, 2012
Altman and Shactman have given us an engaging, comprehensive account of the history of federally managed universally available health care in the United States, but Altman is the central figure and narrator.
The idea of universal health care has circulated among Progressives for more than a century, starting with Teddy Roosevelt. The path included some turns that seem surprising to us now, such as Samuel Gompers, the early 20th century labor leader, opposing it on the grounds that it would weaken the need for unions. Franklin Roosevelt studied the idea, but chose not to pursue it because he felt that it would detract support from his proposal for Social Security. These are examples of the political insights that Altman adds to the historical account.
The modern story begins with Richard Nixon who, according to Altman, came closer to establishing a national health program than any president before Obama. Nixon worked with Senator Ted Kennedy and Congressman Wilbur Mills to enact a program crafted in large part by Altman, who at the time was a deputy assistant secretary of Health, Education, and Welfare. It might have passed except for Mills being caught in in a Washington reflecting pool with a lady of uncertain reputation, Nixon becoming embroiled with Watergate, and Kennedy's continuing problems with Chappaquiddick. Nixon did, though, manage to enact the Health Maintenance Act of 1973, a "historic" piece of legislation that greatly expanded the availability of HMOs by requiring all employers to offer them if any health plan was provided.
The story continues with the Hill Burton Act, which requires hospitals to treat indigent patients up to a certain fraction of their business. Then on to Medicare, Medicaid, Reagan's disastrous foray into Catastrophic coverage, HIPAA, SCHIP,and Bush's Prescription Drug Program. In each case, Altman provides not only a fascinating account of the political horse trading and arm twisting that led to the final bills, but sufficient description of the various plan concepts and concerns of the interested pressure groups for the reader to appreciate the process.
A continuing theme is the question of cost, and who pays it. Altman makes the case that previous attempts to pass a national program failed because they tried to control costs at the same time they expanded coverage. Every specific cost reduction is someone's livelihood, so it motivates strong opposition. Obama succeeded in part because he avoided any serious attempt to control costs. Instead he emphasized universal coverage and prevented the admittedly huge costs from appearing in the federal budget by imposing them directly on individuals, the insurance and medical industries, and Medicare recipients.
Obama Care was passed as a complex combination of House and Senate regular and budget reconciliation bills that can be seen as either legislative brilliance or Chicago thugery, depending on one's sense of statecraft. Altman provides the raw material for making either case.
He is clearly a committed Progressive who believes that a nationally controlled and supported health care system is a worthy and achievable objective. He would prefer a single-payer government run medical system, but feels that starting with a system cobbled together using the appearance of some individual choice for consumers and providers was the only way to pass the law. It is also clear that he is comfortable with the basic financing principle of taking as much as necessary from those with the ability to pay in order to give to others according to their need.
He is, however, professional enough to provide a fair exposition of the competing positions in the long history of the issue. In this respect, he describes in some detail the positions of groups such as hospital associations, factions of the Catholic Church, the pharmaceutical industry, and unions; all of whom had serious objections to elements of early versions of the program, but were eventually brought around by a variety of gifts, concessions, or ambiguities. The remaining unconvinced opposition is dismissed as "conservatives", or Republicans who simply could not vote for anything that would give the Democrats a victory. While this clearly exposes Altman's bias, it doesn't detract from the value of his story as long as the reader can apply the appropriate filter.
The only real gap in the book is the complete absence of any consideration of the enumerated powers granted to the federal government by the Constitution. Surprisingly for a book that thoroughly recounts the history of a profound expansion of federal power; the Constitution itself is never mentioned. (I let my Kindle search for me.) The only oblique reference is to an obscure case (Newsom vs. Vanderbilt), later reversed, that tried to imply that the Hill-Burton Act guaranteed unlimited indigent care, which it did not. I can only conclude that Altman considers the Constitution irrelevant in this context. His entire emphasis is on recounting the relative power and machinations of the various factions, which in my opinion he does well and reasonably fairly.
Aside from the fascinating history, Altman gave me a better picture of the awesome complexity of the modern American medical industry. I cannot imagine a better case for the classical liberal (a la F. Hayek) judgment that no single agency, such as a government, can possibly know enough or be wise enough to manage it to the satisfaction of all concerned. The size of the Obama Care law, some 2000 pages, and its reliance on administrative decisions for fundamental issues are supporting evidence. Its passage without any cloak of consensus, except for negotiation of details among its supporters, bodes ill for the future.