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Jim

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Inside National Health Reform (Volume 22) (California/Milbank Books on Health and the Public)

by John E. McDonough

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Reading for the 2nd time

read in May 2012

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Jim said: " 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 t 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. ...more "

Jun 11, 2012 10:55PM · see review