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California/Milbank Books on Health and the Public
Inside National Health Reform (Volume 22)
This indispensable guide to the Affordable Care Act, our new national health care law, lends an insider’s deep understanding of policy to a lively and absorbing account of the extraordinary—and extraordinarily ambitious—legislative effort to reform the nation’s health care system. Dr. John E. McDonough, DPH, a health policy expert who served as an advisor to the late Senator Edward Kennedy, provides a vivid picture of the intense effort required to bring this legislation into law. McDonough clearly explains the ACA’s inner workings, revealing the rich landscape of the issues, policies, and controversies embedded in the law yet unknown to most Americans. In his account of these historic events, McDonough takes us through the process from the 2008 presidential campaign to the moment in 2010 when President Obama signed the bill into law. At a time when the nation is taking a second look at the ACA, Inside National Health Reform provides the essential information for Americans to make informed judgments about this landmark law.
360 pages, Hardcover
First published August 13, 2011
27 people are currently reading
258 people want to read
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Displaying 1 - 15 of 15 reviews
July 9, 2020
Would highly recommend to anyone who wants to learn more about the American healthcare system and the policies that govern it. McDonough manages to break down the ACA, a 2000 page law filled with nuance and complexity, in a way that is both accessible and interesting. Might be a little dry to some readers, but I found the content fascinating and McDonough manages to keep it somewhat narratively engaging even when discussing topics like the insurance market, taxation, and budgeting.
January 28, 2013
UPDATE: Have now completed the entire book. Still retains 4 star rating for me. McDonough does more than just paraphrase a 2000+ page bill. Indeed, he frames the significance of this legislation, citing it as not a once-in-a-generation act, but more of a "once-in-every-other or once-in-every-third" generation kind of bill. And after reading, in detail, what impact each title will make, I tend to agree. Further, he aptly points out the many bipartisan aspects of the act, and tells, at times, riveting accounts of what political maneuvering was necessary to get them passed. Every single vote needed be to bartered.
Health care interest or not, if you have an interest in contemporary American politics this is a must-read.
******
I read chapters 3 and 4 before hearing the writer speak in our health policy course. Really a passionate (and quite partisan) man, who was clearly on the inside and knows the ACA, as well as what it took to pass it, inside and out. His book goes deep into the political will and the maneuvers by house and senate Democrats to get this bill passed. If you're interested in health care reform, or politics, this is a good read.
Health care interest or not, if you have an interest in contemporary American politics this is a must-read.
******
I read chapters 3 and 4 before hearing the writer speak in our health policy course. Really a passionate (and quite partisan) man, who was clearly on the inside and knows the ACA, as well as what it took to pass it, inside and out. His book goes deep into the political will and the maneuvers by house and senate Democrats to get this bill passed. If you're interested in health care reform, or politics, this is a good read.
February 7, 2023
This shit is more surreal than any of the fictions I read in the past couple years. Need to improve my fiction choices is the obvious logical conclusion here. /s
March 19, 2018
"The ACA is a product of naked and enormous self-interest and an act of public-interest legislative politics of the highest order; way too expensive and not nearly expensive enough; the result of a seriously bipartisan and excessively partisan process; covered better than any similar public policy controversy in the history of the modern media and not covered well enough at all; done way, way too fast and way, way too slowly; and a vitally important piece of social policy legislation that will save or improve the lives of many, many Americans and a huge experiment that will harm or burden the lives of many many Americans."
This book is a fantastic dive into the legislative process and structure of the Affordable Care Act. The first part of the book largely looks at the process that led to the construction of the law. Starting with the framework of the bipartisan scaffolding in the Massachusetts law and an era of good feeling as Senator Baucus attempted to court key Republican legislators. This start of the process led to many key portions of the act, particularly those involving fraud and abuse and biologics, to involve a great deal of input from key Republican legislators. Indeed, it surprised me how much Grassley was involved in the legislative project and in a way there seems to be a comparative number of ideas that came from him and his staff than those ideas that came from President Obama.
The second part of the book, in my view the heart, outlines the policies that make up the Affordable Care Act. The author does not focus on implementation and I think this choice was good. Certainly in practice some key parts of the ACA such as the medical loss ratio, the individual mandate, the Cadillac tax, the public health prevention fund, and the program for hospital readmission reduction, have not gone as planned either because of politics or unforeseen policy consequences. A brief(er) outline of the law:
Title 1: What most people think of when they think of the ACA is the individual market, which is created by this act along with the regulations that govern these plans as well as extend to employer plans and small group plans. "Obamacare" plans are those on the individual market that are subject to almost all the rules of guaranteed issue, essential health benefits, etc.
Title 2: Medicaid Expansion as implemented has been a much more powerful part of the ACA then thought at the time though also a less powerful part as states have been able to opt out. Although I was interested to notice that Medicaid without the expansion was optional and not in all 50 states until 81
Title 3: Medicare changes. A lot of these have not been the political flash-points that have been present in Title 1 and elsewhere in the law. They encompass administrative simplification, innovation of payment models, bundling, and readmission requirements.
Title 4: Prevention portions of the law: This part gives the USPSTF more teeth and at the same time was embroiled in controversy over mammograms as I have, frustrated, noted before. It also established the Prevention and Public Health fund as well as funding for community health centers and a decent number of other projects.
Title 5: Workforce provisions: As the ACA has moved us toward universal coverage I have seen experts say that the problems of access in America will start looking more and more like a shortage of primary care than of lack of insurance. Title V did not go far enough but it did expand scholarship as well as make attempts to expand primary care training and incentive to expand access in areas that have a shortage of doctors.
Title 6: Addresses conflicts of interest, public reporting of quality information and compliance, creates comparative clinical outcomes research public private partnership, looks at Fraud and abuse. This title is a broad array of programs that don't fit anywhere else
Title 7: Biosimilar twelve year exclusivity period. That's pretty much it
Title 8: CLASS Act: Long term care insurance that pays out money if a person becomes disabled enough to need help living in the day to day life. TBH I did not even know this was in the ACA. Or if I had at some point I had forgotten.
Title 9: Revenue, from high income, to insurance, to tanning beds, to closing loopholes on fuel. This is a lot of how the ACA was paid for (along with title 3)
Title 10 and the sidecar reconciliation edited all of the previous titles.
I really really liked this book.
This book is a fantastic dive into the legislative process and structure of the Affordable Care Act. The first part of the book largely looks at the process that led to the construction of the law. Starting with the framework of the bipartisan scaffolding in the Massachusetts law and an era of good feeling as Senator Baucus attempted to court key Republican legislators. This start of the process led to many key portions of the act, particularly those involving fraud and abuse and biologics, to involve a great deal of input from key Republican legislators. Indeed, it surprised me how much Grassley was involved in the legislative project and in a way there seems to be a comparative number of ideas that came from him and his staff than those ideas that came from President Obama.
The second part of the book, in my view the heart, outlines the policies that make up the Affordable Care Act. The author does not focus on implementation and I think this choice was good. Certainly in practice some key parts of the ACA such as the medical loss ratio, the individual mandate, the Cadillac tax, the public health prevention fund, and the program for hospital readmission reduction, have not gone as planned either because of politics or unforeseen policy consequences. A brief(er) outline of the law:
Title 1: What most people think of when they think of the ACA is the individual market, which is created by this act along with the regulations that govern these plans as well as extend to employer plans and small group plans. "Obamacare" plans are those on the individual market that are subject to almost all the rules of guaranteed issue, essential health benefits, etc.
Title 2: Medicaid Expansion as implemented has been a much more powerful part of the ACA then thought at the time though also a less powerful part as states have been able to opt out. Although I was interested to notice that Medicaid without the expansion was optional and not in all 50 states until 81
Title 3: Medicare changes. A lot of these have not been the political flash-points that have been present in Title 1 and elsewhere in the law. They encompass administrative simplification, innovation of payment models, bundling, and readmission requirements.
Title 4: Prevention portions of the law: This part gives the USPSTF more teeth and at the same time was embroiled in controversy over mammograms as I have, frustrated, noted before. It also established the Prevention and Public Health fund as well as funding for community health centers and a decent number of other projects.
Title 5: Workforce provisions: As the ACA has moved us toward universal coverage I have seen experts say that the problems of access in America will start looking more and more like a shortage of primary care than of lack of insurance. Title V did not go far enough but it did expand scholarship as well as make attempts to expand primary care training and incentive to expand access in areas that have a shortage of doctors.
Title 6: Addresses conflicts of interest, public reporting of quality information and compliance, creates comparative clinical outcomes research public private partnership, looks at Fraud and abuse. This title is a broad array of programs that don't fit anywhere else
Title 7: Biosimilar twelve year exclusivity period. That's pretty much it
Title 8: CLASS Act: Long term care insurance that pays out money if a person becomes disabled enough to need help living in the day to day life. TBH I did not even know this was in the ACA. Or if I had at some point I had forgotten.
Title 9: Revenue, from high income, to insurance, to tanning beds, to closing loopholes on fuel. This is a lot of how the ACA was paid for (along with title 3)
Title 10 and the sidecar reconciliation edited all of the previous titles.
I really really liked this book.
September 17, 2018
A wonderfully detailed look at one of the biggest pieces of legislation in the last 100 years, I would highly recommend this for not only a comprehensive guide to the affordable care act, but also for an in depth look at the legislative process. It’s impossible to tell how people, constituencies, politics, or systems truly affect the final form of a bill as it’s signed into law, but you can catch a glimpse at some of that here
June 12, 2012
This book was highly recommended to me by someone in the health policy business. She needed it back relatively quickly to get it signed by the author, who is her close personal friend. Add to this the fact that the author states on the cover and in the book, more than once, that he is "biased," and you have full disclosure now on any "bias" I might appear to have in rating this book.
That said, I found the book to be highly informative, although it appears to have been rushed, since there are many redundant statements and unnecessary, agenda-driven trivia, which I imagine a good editor would have pulled. I was nevertheless surprised that the ACA was the result of an amalgamation of prior work by a bipartisan, albeit Democratic-heavy, group formed before Obama was even the clear winner of the nomination and informed by numerous key opinion leaders including the AMA, chambers of commerce representing businesses, and the health insurance industry. Much of the law was borrowed from the Massachusetts health care reform act, which was largely the work of many of the same players - Romney himself was a late-comer to that party, too. Statements made by both sides that ACA is exclusively "Obamacare" or the Massachusetts law is "Romneycare" appear to be substantively hyperbolic, if not outright lies created by both parties, who know the truth. Furthermore, McDonough states that the insurance and business lobbies got involved/motivated after early foot-dragging because they realized that they wanted to see one consistent, predicable federal law - with an insurance mandate - rather than having to deal with a "hodgepodge" of different state laws - given that people don't always conveniently get sick in their home state!
The book states that the ACA stands on a three-legged stool, and if it were to lose any of them, it would flounder: banning discrimination in the insurance market (i.e. a return to the "community-based" insurance model started by the likes of Blue Cross/Blue Shield in the 20's rather than the more recent shift to "actuarial-based" plans seen today); mandating that individuals purchase insurance (i.e. simple concept that a shared burden reduces the average cost the way insurance is supposed to work); and, providing subsidies to low-income individuals below the Federal Poverty Level (i.e. the ones who we pay higher emergency care costs for now, because they can't afford insurance - about 46 million plus people and growing). This is a portrayal that has been consistently supported by professors at Harvard and MIT as well as this author - a professor at Michigan. It was also supported by many of the Republicans in the group who helped craft both laws, including Mitt Romney.
Is the MA act any bellwether for the ACA? Polls consistently suggest that better than 60% of the people of Massachusetts are satisfied with their state's health care act and it certainly accomplished its goal of insurance for all, with over 98% of MA residents covered. What is not clear is the cost containment result of the law. Medical care costs in MA still continue to rise - at near alarming rates. While the book addresses some of these cost issues, I find it to be a gloss at best. Most of the book centers on how the law was created and what is in it and not a lot on detailed financials or economics. However, to be fair, little can intelligently be said about cost until MA reaches some kind of steady-state - but Americans do not appear to have that kind of patience with experiments.
That said, I found the book to be highly informative, although it appears to have been rushed, since there are many redundant statements and unnecessary, agenda-driven trivia, which I imagine a good editor would have pulled. I was nevertheless surprised that the ACA was the result of an amalgamation of prior work by a bipartisan, albeit Democratic-heavy, group formed before Obama was even the clear winner of the nomination and informed by numerous key opinion leaders including the AMA, chambers of commerce representing businesses, and the health insurance industry. Much of the law was borrowed from the Massachusetts health care reform act, which was largely the work of many of the same players - Romney himself was a late-comer to that party, too. Statements made by both sides that ACA is exclusively "Obamacare" or the Massachusetts law is "Romneycare" appear to be substantively hyperbolic, if not outright lies created by both parties, who know the truth. Furthermore, McDonough states that the insurance and business lobbies got involved/motivated after early foot-dragging because they realized that they wanted to see one consistent, predicable federal law - with an insurance mandate - rather than having to deal with a "hodgepodge" of different state laws - given that people don't always conveniently get sick in their home state!
The book states that the ACA stands on a three-legged stool, and if it were to lose any of them, it would flounder: banning discrimination in the insurance market (i.e. a return to the "community-based" insurance model started by the likes of Blue Cross/Blue Shield in the 20's rather than the more recent shift to "actuarial-based" plans seen today); mandating that individuals purchase insurance (i.e. simple concept that a shared burden reduces the average cost the way insurance is supposed to work); and, providing subsidies to low-income individuals below the Federal Poverty Level (i.e. the ones who we pay higher emergency care costs for now, because they can't afford insurance - about 46 million plus people and growing). This is a portrayal that has been consistently supported by professors at Harvard and MIT as well as this author - a professor at Michigan. It was also supported by many of the Republicans in the group who helped craft both laws, including Mitt Romney.
Is the MA act any bellwether for the ACA? Polls consistently suggest that better than 60% of the people of Massachusetts are satisfied with their state's health care act and it certainly accomplished its goal of insurance for all, with over 98% of MA residents covered. What is not clear is the cost containment result of the law. Medical care costs in MA still continue to rise - at near alarming rates. While the book addresses some of these cost issues, I find it to be a gloss at best. Most of the book centers on how the law was created and what is in it and not a lot on detailed financials or economics. However, to be fair, little can intelligently be said about cost until MA reaches some kind of steady-state - but Americans do not appear to have that kind of patience with experiments.
April 1, 2012
It is what it is advertised to be: an introduction to the ACA and the political context around it, how and why its sections came about, and where all the media turmoil fits into the larger act.
I read it to be able to think and talk intelligently about the law amidst the flurry of debate and objection against it, and it is the best and most comprehensive source I have found for doing that.
I appreciated how the author talked about what the effect of the law might be, where the challenges in implementation are, and what the big risks and experiments are. I found it partisan only in that his projections for the future of the law were generally positive...in the arguments surrounding each section I thought he did a good job of chronicling the whole debate.
I can't say that it was the most thrilling page-turner I have read, and parts of it that dealt with the budgetary aspects of the law were quite dense, but in general it was surprisingly accessible to me, who is someone with no background in policy.
I read it to be able to think and talk intelligently about the law amidst the flurry of debate and objection against it, and it is the best and most comprehensive source I have found for doing that.
I appreciated how the author talked about what the effect of the law might be, where the challenges in implementation are, and what the big risks and experiments are. I found it partisan only in that his projections for the future of the law were generally positive...in the arguments surrounding each section I thought he did a good job of chronicling the whole debate.
I can't say that it was the most thrilling page-turner I have read, and parts of it that dealt with the budgetary aspects of the law were quite dense, but in general it was surprisingly accessible to me, who is someone with no background in policy.
September 22, 2012
Perfect summary of the ACA for an intermediate knowledge level. This book is an overview of U.S. health reform, with just enough narrative on the political process to make it interesting, and enough policy to make it substantive and informative. Definitely read this at the right moment. Had I read it eight months ago, it would have been over my head. McDonough is a policy expert and high-ranking Hill staffer, and he's able to provide in-depth knowledge of both the policy considerations and the political process. And he's a good enough writer to articulate it all. Exactly what I was looking for.
May 3, 2014
Love it or hate it, the Affordable Care Act is a very significant piece of legislation affecting health care in the US. The first half of the book gives a very interesting and detailed account of how the legislation was formed and ultimately passed. The second half gives a fairly detailed explanation of each section of the ACA. I feel like I have a much better understanding of the good, the bad and the ugly of the legislation. I highly recommend it to anyone who works in our health care system or who wants to understand this comprehensive law.
November 4, 2013
This was a very informative book about the changing healthcare landscape in America. The first two sections of the book go into a lot of unnecessary detail, but the third section, which outlines the major parts of Obamacare, is extremely helpful. This book will really help you understand the future of the U.S. healthcare system.
June 3, 2012
Written by a liberal, but in general is a pretty even handed account of the ACA. Good introduction if you want to knw what is in the law and a bit of the politics involved in passing it. Of course the really underhanded stuff has been left out.
September 20, 2011
Good, not great. I thought it would be more like David Broder's The System. Very partisan, but I guess that was to be expected.
January 16, 2012
Great background and resource for the topic.May be a bit dense for some. But an interesting account of one of the most historic legislation in our nation's recent history.
February 18, 2013
A fabulous overview of both substance and process.
May 19, 2013
plan to re-read the second half again. Until then...
Displaying 1 - 15 of 15 reviews