Health care policy has attracted considerable attention in recent years from scholars, journalists, and policy makers. After a century-long struggle over health care reform, landmark health care legislation became law in 2010. Enactment of the Affordable Care Act (ACA)—hailed as the most sweeping social welfare measure to pass Congress since Social Security was established in 1935—has, in large part, spurred academics and others to scrutinize, and write about, health policy. The resulting books greatly enhance our understanding of the United States health care system.
This essay examines health care reform and the ACA through a critique of four recent, notable contributions to the literature: Paul Starr’s Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform, revised edition (2013); Reference Starr1 Steven Brill’s America’s Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System (2015); Reference Brill2 Ezekiel Emanuel’s Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System (2014); Reference Emanuel3 and, Stephen Davidson’s A New Era in U.S. Health Care: Critical Next Steps Under the Affordable Care Act (2013). Reference Davidson4 These books highlight the broad interest in health care policy, with authors representing diverse professional orientations and experiences.
Starr, a professor of Sociology and Public Affairs at Princeton University, boasts insider credentials beyond his academic ones—he focused on enacting health care reform as a senior White House health policy adviser under President Bill Clinton. Brill, a writer, lawyer, Yale University journalism instructor and more, is known for delving into complicated and salient policy issues. A generalist, Brill lacked health care policy expertise when he began investigating America’s health care system for his 2013 Time magazine story. Reference Brill5 In contrast, Emanuel, a professor of Medical Ethics and Health Policy at the University of Pennsylvania and founding chair of the National Institutes of Health Department of Bioethics, has firsthand medical and political knowledge. Trained as an oncologist specializing in breast cancer, Emanuel also was intimately involved with the ACA’s development, serving as a senior adviser on health care to President Barack Obama’s Office of Management and Budget (OMB) from 2009–2011. And Davidson, a professor of Health Policy and Management at Boston University, has been engaged in the health care system as well, but from the delivery end rather than the policy making end. Davidson served on the board of a small, non-profit health center in Rhode Island.
This essay is organized into three sections. I first provide some general reflections on health care reform and the ACA through an examination of the authors’ explicit and implicit agreement on several key matters. I then critique each book’s strengths and weaknesses. Finally, I briefly explore a key difference among these four authors’ discussions of the ACA.
Reflections: Health care reform and the ACA
Notwithstanding the authors’ varying objectives and areas of expertise, several observations percolate up from considering similarities in their arguments and analyses. At the outset, I should note that all four writers believe that the pre-ACA health care system needed an overhaul, and they do not shroud their lack of neutrality here. Furthermore, they appreciate that the ACA represents the most significant health care reform measure since Medicare was enacted in 1965. These four authors also advocate additional reform to solve the nation’s health care deficiencies. Beyond generally supporting the ACA, the authors recognize that the ACA’s passage represents a landmark legislative accomplishment. Yet they also desire further changes to the health care system. These and other noteworthy parallels emerge across the four books reviewed here.
Unlike much of the scholarship in American politics, Starr, Brill, Emanuel, and Davidson all understand that, as the “living legislation” approach demonstrates, a legislative triumph is only one component of any battle for reform. Reference Jenkins, Patashnik, Jenkins and Patashnik6 In other words, passing the Patient Protection Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010 (HCERA), which together comprise the ACA, may have established the framework for expanding health insurance coverage and restraining health care costs, for instance, but it was not tantamount to achieving and sustaining these goals. Although the writers do not identify the living legislation perspective, they grasp that enacted measures must be consolidated and “remake politics” if they are to endure, Reference Patashnik and Zelizer7 and that “the capacity of reforms to remake politics is contingent, conditional, and contested.” 8 Within this shared theoretical foundation, the authors largely subscribe to the “policy feedback” argument, emphasizing that, as Patashnik and Zelizer underscore, policies help “shape the political landscape by altering state capacities, changing incentives for collective action, and encouraging social adaptations that may become difficult to reverse.” 9
The authors also neither blindly support the whole ACA nor the Democrats, who enacted the law without a single Republican vote. In short, each writer brings at least a modicum of balance to his work. There is consensus, for example, that the ACA falls short in significant ways: Starr and Brill criticize deficient cost containment provisions; Emanuel, whose endeavors at the OMB centered on achieving cost controls, touts the ACA elements aimed at reducing health care prices, but regrets the limited action on payment reform; and Davidson laments that the ACA fails to tackle problems in the most direct and strongest manner, for instance, by creating a universal health insurance program. (Note, however, that none of these authors critique the ACA from a social justice standpoint, as does Gunnar Almgren, who opposes the ACA’s reliance on Medicaid to expand health insurance coverage based on Medicaid being a “highly stigmatized means-tested entitlement program . . . of poverty and dependence” that fails to translate into “the same level of health care access as [one receives with] the possession of a health insurance card.” Reference Almgren10 ) All four authors similarly express discomfort or displeasure with how the ACA’s passage resembled sausage-making with backroom deals, logrolling, special concessions for wavering senators, and much more. And each book criticizes the ACA’s implementation as well—a process fraught with mishaps and protracted battles on multiple fronts—yet claims that the ACA should be the foundation for future health care reform.
Along the same lines, the writers all recognize that legislating on health policy inevitably yields unintended consequences. They implicitly agree, too, that the ACA’s unintended negative consequences do not outweigh its intended and real benefits, such as decreasing the numbers of uninsured Americans. Starr and Emanuel include superb examinations of the “whack-a-mole” phenomenon (solving one problem only to have another pop up elsewhere) in health care policy making, its inevitability, and its profound impact on the health care system.
The three authors who chronicle health care reform’s historical journey—Starr, Brill, and Emanuel—concur in the often overlooked point that the ACA has strong Republican roots. The books highlight former GOP Governor Mitt Romney’s trailblazing health policy achievements in Massachusetts, with enactment of a near-universal health care program. Romney’s promotion of the individual mandate as “the ultimate conservative idea” of individual responsibility, a notion the Heritage Foundation endorsed, is one of the ACA’s great ironies, given the vehement GOP opposition to requiring that individuals maintain a minimum level of coverage. 11 The authors also stress the ACA’s conservative pedigree beyond the individual mandate. The state-based insurance exchanges, for example, began as a GOP proposal, embody conservative ideals of choice and competition, rely on private insurance, and respect the Republican case for federalism.
Regarding the GOP, these writers rightly show that despite the Republicans’ unanimous opposition to the ACA in Congress, congressional Democrats initially sought to make health care reform bipartisan. At first, bipartisanship did not seem unrealistic, considering that earlier GOP proposals provided the genesis of Democratic proposals in 2009. Brill’s description of Democrats’ efforts to make health care reform bipartisan, based on his interviewing of inside players, stands out.
Not only did congressional Republicans unanimously oppose the ACA, but as these books vividly portray, the ACA was “born in a bubbling cauldron of party vitriol.” Reference Jacobs and Callaghan12 Republicans were intent on delegitimizing, undermining, and quashing Democratic efforts. The intense partisanship inspired GOP obstructionist tactics, opposition rhetoric with inflammatory language, and an overall poisonous atmosphere. Republicans adopted such an uncompromising mindset that a senior GOP Senate aide complained, “My boss’s colleagues were mad at him for going to the White House and just talking to Obama.” Reference Burgin and Bereznyak13 Not only did the ACA’s enactment fail to cool the bubbling partisan cauldron in Washington, DC, but with the law’s devolution of policy responsibilities to the states, new ACA-related partisan hostilities spread across the nation.
Each book in its own way also reminds readers that “people matter” in politics, policy making, and policy implementation. In stating his book’s aim, Starr stresses that he will be “attentive to . . . the critical choices that political leaders and other individuals have made.” 14 Using historical examples and describing attempts to modify the U.S. health care system, Starr illustrates how the “private lives and political fortunes of individual leaders” mattered. 15 Brill adopts a personality-driven perspective, illuminating how elected and unelected officials’ temperaments, and their seemingly minor personal and professional decisions, impact history. He introduces influential actors inside and outside government, and underscores how health care policy was often a personal issue for these individuals, as well as a political issue. The authors all depict, in their discussions of leaders artfully utilizing windows of opportunity, what political scientist John Kingdon dubbed a “policy entrepreneur.” Reference Kingdon16 An entrepreneur may traditionally have been viewed as a single legislator poised with an initiative and documentation of a problem to readily capitalize on a policy opening; however, these books reveal a more diverse set of characters—including elected and unelected officials in states and the federal government, as well as individuals in the private sector—whose actions resemble those of successful entrepreneurs. Reference Burgin17
All of these authors credit President Obama with playing a key role in the ACA’s passage. Obama’s commitment to reform grew over time, and without his leadership, they assume that the ACA would not have become law. Despite not being well-versed on the health care system when launching his presidential bid, by the start of his presidency health care overhaul had catapulted to President Obama’s top priority. While the writers applaud Obama’s resolve and persistence when reform efforts hit major obstacles prior to passage, they similarly criticize his approach to governing after the ACA’s enactment.
In terms of other critical players, each book also highlights stakeholders in the health care field with competing agendas who participated in the reform process, and who have impacted reform efforts over the years. There is a general consensus that, historically, support for the status quo among such entrenched interests as insurance and pharmaceutical companies, hospitals, physicians, and health care businesses impeded reform. And although these stakeholders affected reform in 2010, they did not prevent it. Indeed, President Obama and the Senate Finance Committee struck deals with the major hospital associations and pharmaceutical companies (e.g., to not include importation of cheap drugs from abroad in the legislation) to neutralize opposition and secure support.
Finally, the authors uniformly underscore that policy makers continually learn from prior attempts at reform. For example, President Clinton’s failure to overhaul health care in the 1990s helped shape the Obama administration’s approach in crafting and securing passage of the ACA. As Emanuel asserts, “When it comes to health care reform, the past is truly prologue.” 18 Nevertheless, as Davidson writes, “knowing the history of prior reform efforts,” President Obama overruled his advisers who opposed expending political capital on health care at the start of his presidency. 19 Significantly, though, rather than foisting a detailed reform blueprint on Congress (as had President Clinton), President Obama tasked Congress with writing the legislation. But recognizing the lesson about deferring to Congress was easy for President Obama because, as Starr posits, “he and congressional Democrats agreed on the model for reform, and the congressional leadership did not need or want White House intervention at that point.” 20 Moreover, deferring to Congress was politically advantageous for President Obama, sparing him the need to publicly reverse himself on his earlier opposition to an individual mandate; instead, Obama could simply agree to the mandate Congress integrated into its legislation. With the authors’ emphasis on the Obama administration’s efforts to avoid President Clinton’s mistakes, however, they all overlooked what Rahm Emanuel, Obama’s first chief of staff and former Clinton aide, stressed: “The No. 1 lesson from 1993 . . . was to make sure you could use reconciliation [a procedural device that cannot be filibustered Reference Burgin21 ] for health care.” Reference Hulse22 This was especially important given how former Senator Robert Byrd (D-WV) foreclosed that strategy for President Clinton. Reference Mann, Ornstein, Mann and Ornstein23
Overview and analysis
Despite the substantive similarities among these four books, each work offers the reader something quite unique. I now turn to these contributions, as well as to each book’s strengths and weaknesses.
Starr’s scholarship
Paul Starr’s Remedy and Reaction presents a logical starting point, since the other authors utilize his writings. Reference Starr24 Starr provides an insightful historical and social science scholarly analysis of the U.S. health care system conundrum. Chronicling the uniquely American struggle over health care reform, he examines the effect of political, economic, and social influences and developments. Starr’s judgments are sharp, perceptive, provocative, and revealing. Three particular elements in his book stand out.
First, Starr declares at the outset that Remedy and Reaction addresses “why health care in the United States became so vexed a problem,” 25 and he persuasively presents his central theme. He shows that America “ensnared itself in a policy trap, devising an increasingly costly and complicated system that has satisfied enough of the public and so enriched the health-care industry as to make change extraordinarily difficult.” 26 Without employing the living legislation or policy feedback terminology, Starr nonetheless underscores their centrality. Health care has become so politically contentious and resistant to reform in the U.S. more due to the unintended consequences of incremental actions, events, and decisions than because it is an intrinsically intractable policy arena.
Matters that were neither perceived at the time as monumental nor carefully vetted policy determinations set the policy trap’s foundation, Starr contends. During World War II, for instance, millions of unionized workers won health insurance as a means of providing added compensation, notwithstanding federal wage-and-price controls. Then, under President Harry Truman, Congress approved federal dollars for modern medical facilities and medical research, Congress supplied the groundwork for Medicaid (by partially reimbursing states for welfare recipients’ medical costs), and a presidential study group proposed that seniors on Social Security receive 60 days of hospital coverage (serving as the genesis for Medicare). From the early 1950s to mid-1960s, the “protected public” expanded more: individuals with employer-sponsored health insurance received tax benefits when the Internal Revenue Service (IRS) deemed such employer contributions tax-exempt; Congress created Medicare for the elderly (without including cost controls); and, Congress established Medicaid as a mixed federal/state program for the poor. (Starr also notes that since World War I veterans have been compensated with a separate medical and hospital system.)
Remedy and Reaction argues that these various entitlements instilled a “psychology of self-exemption” among the so-called protected public, 27 and acted as a prophylactic against a universal health insurance system rather than furnishing its basis. Many beneficiaries failed to recognize that they received direct or indirect government assistance, and thus had something in common with uninsured individuals:
The tax subsidies for employment-based insurance are nearly invisible to those who receive them; Medicare invites seniors to believe that they have earned its benefits, whereas other claimants have not. Morally armed, they can reject helping others in need as a matter of high principle; after all, Americans shouldn’t look to the government for help. 28
Starr maintains, in fact, that every part of the health care financing system conceals its real price tag.
According to Starr, a confluence of factors that independently may not be sufficient to stymie reform, together have produced a dysfunctional U.S. health care system with built-in barriers to improvement. The health care industry, including insurance enterprises, pharmaceutical companies, hospitals, and physicians, for example, benefits or profits from rampant medical inflation and exorbitant costs, and hence contributes to the policy trap. Starr also shows how the system’s complexity—economically, psychologically, and politically—reinforces the trap. Many Americans do not fully comprehend their own health insurance and health insurance interests, e.g., that the government may be substantially subsidizing their insurance by excluding their employer’s contribution from taxable income. The system’s complexity, as well, tends to engender confusing proposals that simultaneously seek to address the system’s myriad challenges. Opponents can then exploit the reform proposals’ complexity, in a broader climate of low trust in government, to spark opposition to reform.
Artfully tracing the evolution of the health care system and rise of health insurance, Starr reveals the magnitude of the policy trap and how it has ensnared the nation. Through his comprehensive historical journey he illuminates trends and patterns over the years, and stresses the significance of several policy-related or contextual factors: (1) the private, employer-based insurance system that obscures its costs from beneficiaries; (2) government program recipients such as seniors and veterans, who receive broad popular support, enlist vocal advocates, and perceive their entitlements as earned and superior to those of Medicaid recipients; (3) the increasing health care costs that have enriched the growing health care industry, which powerful groups protect; (4) the innumerable incremental changes to the system over the years (e.g., the expansion of managed care, the creation of the State Children’s Health Insurance Plan [SCHIP], etc.), and their unintended consequences; and, (5) the ideological opposition to universal health insurance. Starr highlights how the policy trap has thwarted both parties from achieving their goals, and he unpacks such complicated issues as competing approaches to reform, the operations of a managed care network, and how policy makers unintentionally turned private insurance into managed care. Starr’s analysis of the policy trap rings true and furnishes rich detail.
Second, the combination of Starr’s scholarly expertise, exacting research methods, and firsthand experience in health care politics during the Clinton administration are formidable. His substantive health policy expertise complements his appreciation of the empirical realities of congressional and executive behavior as well as of political and institutional constraints. Despite Starr’s acknowledgement that he is not neutral about reform, one can still witness a balance in his work, born out of rigorous scholarship, that is uncommon for those who have “lived within the beast” of Washington politics. Having made the transition from political insider, Starr presents empirically supported arguments in an intellectually grounded manner, with well documented and exhaustive primary and secondary source research. He engages, applies, and refutes scholarly literature handily. 29
Starr’s interviews with key players engaged in recent health care battles further enhance Remedy and Reaction—he unveils significant behind-the-scenes maneuvering and sheds light on participants’ actions and motives. Take, for example, Starr’s narrative regarding Romney’s decision to include an individual mandate in the Massachusetts health care reform. Starr describes Romney’s meeting with political and policy advisers, based on several participants’ accounts, at which they considered “whether the mandate was ‘consistent with our principles’ . . . [and whether Romney could] ‘do this as a Republican.”’ 30 Starr’s approach of interviewing influential political actors grows naturally out of his own experience, and he approaches his analysis with a recognition of what his sources have to offer.
Starr’s own political experiences undoubtedly contributed to his nuanced understanding of politics. In addressing such topics as intra-party compromise, 31 House-Senate differences, 32 and why President Obama succeeded on health care reform and not on climate change legislation, 33 for instance, Starr explains issues with clarity. And without identifying the “permanent campaign” by name (a matter that political scientists have studied in depth), 34 Starr explores its impact on Congress’s ability to pass major health care reform. Consider Republicans’ electoral strategy throughout the health care reform debate—stifle the Democrats by becoming the “party of no,” and cultivate an issue to run against (i.e., “Obamacare” with its purported “death panels”). Starr provides similarly keen observations about lawmakers’ perpetual election mentality in his discussions of Senator Charles Grassley’s (R-IA) fear of being “primaried” from the right, 35 and the conservative campaign to make health care reform Obama’s “Waterloo” in order to “break him” politically. 36 As Brady and Fiorina found, when partisan differences exist, “parties calculate whether they have more to gain [electorally] by reaching an acceptable compromise and claiming bipartisan credit, or by accepting—or even creating—a stalemate and trying to lay blame on the other party.” Reference Brady, Fiorina, Ornstein and Mann37 Even when members of the opposition do not disagree with a president’s proposals, they “have an electoral stake in the president losing.” Reference Lee38
Third, Starr integrates theoretical underpinnings of the health care system and health care reform into his analysis. Although his approach is not primarily conceptual or theoretical, he introduces some public philosophy dilemmas such as fairness versus equality, and responsibility versus freedom, into his account. Starr also illuminates how liberal and conservative reformers, as well as stakeholders in the health care system, have tried to use both theoretical and moral arguments. For instance, Medicare grants recipients a type of moral claim, since it is touted as “an earned right, even though seniors have never paid enough in payroll taxes to earn their insurance coverage”; 39 Medicaid, on the other hand, perceived as a program “shackled to public assistance (‘welfare’),” 40 lacks such a moral claim. Similarly, Starr juxtaposes the rights and obligations associated with Medicare and Medicaid with the rights and obligations associated with excluding employer health insurance contributions from employees’ taxable income.
As with any serious work, one inevitably encounters errors and nits to pick. Several limitations to Remedy and Reaction should be noted. First, Starr appears to present a simplified picture of a more complex situation regarding intra-party polarization and the ACA’s passage. He writes, “each party was more homogeneous and therefore more capable of enacting legislation on its own if it had a majority in the House and 60 votes in the Senate. In 2010, that is how comprehensive health-care legislation would pass Congress.” 41 This one passage alone has two misleading components. To become the majority in the House and a super-majority of 60 in the Senate, a congressional party caucus in today’s political climate invariably must include a broad spectrum of conflicting views. As scholars and journalists show, the House Democratic majority of 258 seats in 2009 had “splintered into disparate factions,” 42 prompting leaders to focus on “winning just enough support in their moderate flank to succeed.” Reference Cohen and Friel43 A House Democratic leadership aide recalled, “We fought internally; we had a constructive bipartisan debate in our caucus every time we wanted to move something forward.” 44 Another influential House committee staff person elaborated, “The conservative Democrats from conservative districts represent what GOP members want.” 45 The Senate Democratic caucus not only had an analogous “big tent” dynamic, but chamber rules complicated the resolution of intra-party differences: “Every member had a veto in the caucus, and half of them threatened to exercise it. We had to take every threat seriously.” 46 Moreover, conservative Senate Democrats also sought the cover of GOP votes: “[Blanche] Lincoln [D-AR], [Ben] Nelson [D-NE], and others needed to see that [Max] Baucus [D-MT] had made a genuine effort to make the bill bipartisan.” 47
Furthermore, Starr obscures what transpired when he suggests that the ACA passed Congress in 2010 because of the Democrats’ House majority and 60-vote Senate majority. 48 Congress passed the ACA (the PPACA, now PL 111-148, and the HCERA, now PL 111-152) after former Senator Scott Brown (R-MA) won the January 2010 special election to replace former Senator Edward Kennedy (D-MA), and hence when the Senate had 59 Democrats. The Senate’s loss of a 60-member super-majority actually enabled Democrats to enact reform in 2010, because it freed them to use reconciliation. 49 Reconciliation measures cannot be filibustered and require only a simple majority for passage. Reference Davis50 In 2009, after each chamber approved its own separate reform measure, House and Senate Democrats tried to resolve differences through the “ping-pong” process, but appeared to be stuck. Reference McDonough51 Senate Democrats even acknowledged that they could not pass a merged bill with 60 votes—it was moving to the left, 52 and “a tough re-election cycle” was approaching. Reference Herszenhorn and Pear53 If House Democrats could clear the moderate Senate bill, however, Senate Democrats would not have to muster 60 votes again to clear health care reform because the two chambers would have approved identical measures. Yet liberal House Democrats refused to approve the Senate bill with its sweetheart deals for particular senators, Reference Connolly54 and former Representative Bart Stupak’s (D-MI) anti-abortion contingent and the Congressional Hispanic Caucus also steadfastly rejected the Senate bill. 55
Although counterintuitive, the changed Senate landscape following Brown’s election helped Democrats enact reform. Since it became impossible for Senate Democrats to approve a merged bill, House Democrats were forced to make previously unacceptable compromises to achieve comprehensive reform. They agreed to clear the Senate measure, and afterwards immediately pass a sidecar bill of reconciliation corrections that both bodies would approve. This two-step process short-circuited a possible filibuster and death of a compromise meshing the House and Senate measures. 56
Second, Starr skims over key episodes and themes that merit more attention. Indeed, perhaps rather than being a flaw, Starr’s narrative is so compelling that it puts him in the unenviable position of being asked to do more. Nonetheless, the reader may wonder, for instance, how then-Speaker Nancy Pelosi (D-CA) extracted the votes to pass the more moderate Senate bill in March 2010. Because Pelosi’s success here was critical for reform, Starr might have shed light on what transpired. In addition, Remedy and Reaction raises important topics in passing without explicitly addressing them. Take, for example, the notion of bipartisan compromise—its characteristics, possible costs, and “perverse effects.” 57 Starr insightfully highlights the benefits and limitations of “bipartisan incrementalism.” 58 His discussion of the 1996 Health Insurance Portability and Accountability Act (HIPPA), which unanimously passed the Senate and was heralded as a huge achievement, epitomizes the potential price of bipartisan compromise: to achieve a broad majority, the final bill was “so riddled with loopholes” that it essentially rendered its portability provisions meaningless. 59 Rather than just reporting scattered examples of bipartisan compromise, Starr might have purposefully explored the implications of such political phenomenon.
Third, Starr acknowledges his bias regarding health care reform, and his rigorous scholarly approach by and large yields a product that is not blatantly political; however, at points he loses some of this balance and thus diminishes the reference value of his work. In examining President Clinton’s failure at reform (remember that Starr served in the Clinton administration), Starr’s tone periodically becomes angry. He writes, “The Republicans enjoyed a double triumph, not just killing reform but watching the jurors find the president guilty. It was the political equivalent of the perfect crime.” 60 In other places, Starr’s bias emerges through sarcasm. Instead of simply noting that Senate Democrats refrained from filibustering the Medicare Modernization Act (MMA) under a unified Republican government in 2003 after it was meshed with the House version, Starr snipes, “This was in keeping with the apparently unwritten rule for health legislation that the requisite majority was only 51 for a Republican bill but 60 votes for a Democratic one.” 61 He moves from sarcasm to indignation as he continues to address the MMA: “Neither the Clinton administration in 1993 nor the Obama administration in 2009 had the nerve to propose an expanded health-care entitlement without paying for it. But the Republicans in 2003 did exactly that.” 62 In all of these (and other) cases, statements of fact would have sufficed and adequately conveyed Starr’s points.
Brill’s storytelling
Steven Brill’s book, America’s Bitter Pill, builds directly on Starr’s contribution. He agrees with Starr’s analysis of the genesis of our health care system’s dysfunction and the protected public (e.g., beneficiaries of the employer-based insurance system with its tax subsidies, and government program recipients such as seniors with Medicare). In particular, Brill stresses the policy feedback implications of the IRS’s bureaucratic decision to not count workers’ health insurance benefits as taxable wages. According to Brill, this IRS action helped launch “America’s most gaping tax loophole, one that would forever change the course of healthcare in the United States.” 63
Unlike Starr’s scholarly work, however, Brill is an investigative writer who discovers and recounts a gripping suspense thriller. The intrigue revolves around such topics as the twists and turns in health care reform’s drafting and passage, the bitter struggles among powerful forces, and the ACA’s implementation crises and successes. To hook the reader, Brill demonstrates that this is not some distant, inconsequential nonfiction—health care policy is personal, triggering fears of illness, pain, and death, as well as the desire “to do something, anything, to avoid that for yourself or a loved one.” 64 In contrast to Starr’s historical narrative, over half of Brill’s drama concentrates on the ACA’s implementation, a saga whose build-up Brill recounts beginning in 2007.
Before critiquing America’s Bitter Pill, I should note that it does not deliver the tale its title suggests. In Brill’s eyes, the ACA is not a harsh, astringent law that is being forced down our throats. While he deplores the cost of medical care and laments that its quality is “jeopardized by the broken economics of the marketplace,” 65 the ACA’s enactment, despite all odds, impresses him, as does its early success in expanding health care coverage. The book’s subtitle—Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System—as well, does not accurately reflect Brill’s message. Brill deems these backroom deals, referring largely to the pharmaceutical industry’s role in emasculating the efforts to “bend the cost curve,” “to have been worth it, because all of the realistic alternatives were worse.” 66 In short, Brill posits that the power struggles yielded a law that benefits previously uninsured and underinsured individuals, and treats the health insurance industry fairly. On the other hand, he suggests that it fails to reduce exorbitant charges (from hospitals, pharmaceutical businesses, and medical equipment companies), and misses the mark on protecting Americans with cost containment strategies.
The most striking aspect of Brill’s work is its sheer breadth. His rich potpourri of details touches on, and even offers keen insights and fascinating tidbits of information regarding, a vast array of critical topics. Brill delves into such matters as policy makers’ decision making surrounding the crafting and implementation of the ACA, governmental and non-governmental fights, market structure, billing practices, federalism, government organization, and the impact of the health care system on the general public.
While Brill writes for a lay audience, his contribution nonetheless merits scholarly attention even beyond the health policy field. For students of Congress, he explores process, decision making, the dual nature of Congress, partisanship, the impact of lawmakers’ personalities and friendships, the permanent campaign, oversight, and more. Brill reveals, for example, how top administration officials, who were at a minimum evasive and unresponsive (most notably on several occasions in 2013), stymied Congress’s ability to conduct effective oversight. 67 The three other titles reviewed here, focusing more heavily on the executive branch, do not as clearly illuminate such phenomenon.
Brill similarly offers presidential scholars an important case study. He details conflicts within the administration, such as those between the economic policy and health care teams, during both the ACA’s creation and implementation. 68 The reader witnesses the consequential “war of the pens” in preparing President Obama’s 8:00 p.m. reading folder. 69 Despite such internal disputes, Brill underscores that President Obama dislikes confrontation, preferring “to hear solutions, not problems.” 70 Brill also juxtaposes President Obama’s commitment to passing reform with his relative lack of involvement after the ACA’s enactment, and ultimately holds President Obama accountable for the implementation problems:
From the president and Valerie Jarrett [senior Obama adviser, who more than anyone else had “the president’s ear” and “confidence” 71 ] on down, they had sloughed off the details of governing when it came to their most important and difficult domestic initiative. It was as if they either believed that they were . . . above worrying about the details of making the law work, or that they didn’t understand that effective government does not happen automatically. Or both. 72
Brill observes the complexity of implementation from a bureaucratic angle, as well. The reader sees why it matters “who sits at which table in the high school cafeteria,” 73 and how the bureaucratic staff shuffling after the ACA’s passage hindered implementation. Brill attributes part of the ACA’s initial website debacle to Democrats’ attempts to insulate the ACA from GOP funding cuts by demoting the “office” in charge of implementation to a “center.” And he expresses outrage at the government’s own public relations staff and other officials who asserted that they were “walking around with PTSD” after the website’s disastrous launching: “It was emblematic of their amazing ability to be indignant—to assume the role of the victims—when it was their own failure to govern that had fortified and emboldened the opponents.” 74
With his expansive scope, Brill even examines state implementation. The ACA grants states critical responsibilities regarding the creation of health insurance exchanges and the expansion of Medicaid (notwithstanding the Supreme Court’s June 2012 ruling removing the penalty for states not expanding Medicaid), and Brill appropriately reflects the ACA’s devolution of policy responsibilities. States still significantly impact the ACA’s success and entrenchment, and we follow Kentucky’s Democratic Governor, Steven Beshear, and Carrie Banahan, executive director of Kentucky’s Office of Health Policy, as they aggressively respond to the ACA’s letter and intent in a red state. Contrasting Kentucky’s near-flawless development and roll-out of its state exchange with the federal government’s actions, Brill illuminates some strengths of federalism. 75 His earlier coverage of reform in Massachusetts similarly exemplified Justice Louis Brandeis’s notion of a state serving as a laboratory of democracy. 76 But Brill does not sugarcoat federalism; whether in his discussions of states thwarting the ACA through lawsuits, refusing to establish state exchanges, or opting out of the Medicaid coverage expansion, Brill reveals the costs of the ACA’s “delegated governance” model. Reference Morgan and Campbell77 Moreover, he asserts that state fiascos in launching online marketplaces demonstrate how “the federal government didn’t have a monopoly on public works mismanagement.” 78
Beyond delving into government, Brill explores the health care industry and health care system maze. He stresses the industry’s magnitude, employing a sixth of U.S. workers, and how health-related payments constitute the average family’s biggest single expense. Contrary to conventional wisdom, Brill illustrates that the hospital industry’s consolidation—not the insurance industry’s consolidation—contributes most to rising health care costs. The Yale-New Haven and New York-Presbyterian hospital mergers exemplify how medical administrators can overcharge due to their bargaining power relative to insurers’ and patients’ power. 79 Brill also shows that the health care system’s structure constrains policy makers’ responses to the cost/coverage conundrum; it is easier to increase insurance coverage than to battle the American medical industry in attempts to curb costs.
As mentioned, Brill concentrates on the ACA’s ongoing implementation, too. Just a sampling of the varied subjects he examines includes the botched website debut, officials’ incorrect assumptions about easily patching the law’s weaknesses with “fix-it” legislation, the unexpected difficulty in writing the myriad required rules and regulations necessary to implement the law, the absence of a clear hierarchy for the federal exchange’s launching, and the unilateral administration decisions to delay, modify, and scrap ACA provisions, thereby altering the law’s financial equilibrium and Congressional Budget Office (CBO) revenue projections. Within the implementation tale, Brill uncovers misunderstood and overlooked information. Take, for example, the brouhaha over the cancellation letters that millions of Americans who bought their insurance individually received because their policies did not meet the minimum ACA standards, despite President Obama’s earlier promise, “If you like your health care plan, you’ll be able to keep your health care plan.” 80 Unbeknownst to President Obama and key White House staff when the “cancellation grenade” exploded, the Department of Health and Human Services (HHS) had issued pertinent regulations in the June 17, 2010 Federal Register, predicting that 40 to 67 percent of the existing 14 million individual insurance policies would be cancelled under the new rules. 81
In addition to the breadth of America’s Bitter Pill, Brill’s research methods stand out—he interviewed some 243 sources for this effort, many multiple times, and he sets a high standard for attribution and for direct quoting from source materials. 82 Brill’s extensive probing enabled him to uncover new material and offer crucial context. Based on interviews, for instance, Brill recreates parts of the GOP’s strategizing session with pollster Frank Luntz, the very night Democrats were celebrating at inaugural balls. The politics were “pretty clear” that the Republicans had to stop the president on health care reform and ultimately “come up with the arguments and polling” to squelch bipartisanship. 83 The reader similarly obtains a bird’s eye view of the backroom deal making involving White House political operatives, Pharmaceutical Manufacturers Association of America (PhRMA) representatives, Senate Finance Committee staffers, union leaders, and liberal interest group activists.
A further noteworthy feature of Brill’s work is its accessibility. Individuals who are newcomers to health care policy will appreciate Brill’s ability to unpack complex matters. As a self-identified health care “novice,” 84 Brill has a very good understanding of how the system perplexes people. He breaks down jargon, the convoluted system’s functioning, and the theories behind health policy trade-offs. Indeed, whatever Brill is discussing, be it the hospital “chargemaster” system, 85 how reform can generate revenue, 86 or the technological issues affecting implementation, 87 he is clear and concise. The book’s accessibility, however, should not dissuade those knowledgeable about health policy from reading the book: America’s Bitter Pill has much to offer.
The final strength deserving attention is how Brill effectively places people front and center to engage the reader, humanize health policy, and underscore the relevance of health care to every American. Although all four authors reviewed here recognize that “people matter,” Brill’s emphasis on individuals and his personality-driven perspective are most integral to his narrative. By detailing the horrors several Americans faced in the pre-ACA era (with coverage gaps, 88 underinsurance, 89 insurance companies’ refusals to sell individual policies to people with pre-existing conditions, 90 and more), and the human toll of the ACA implementation errors, 91 Brill highlights the system’s complexity and callousness, as well as the importance of understanding it. The book, filled with vignettes and anecdotes, shows how health care touches us all. Brill even includes his personal experience with the system when he required immediate surgery on an aortic aneurysm while finishing America’s Bitter Pill, and how this personal health scare helped him appreciate the difficulty of controlling costs:
When you’re staring up at someone from the gurney, you have no inclination to be a savvy consumer. You have no power. Only hope. And relief and appreciation when things turn out right. And you certainly don’t want politicians messing around with some cost-cutting schemes that might interfere with that result. 92
Brill also uses this human interest perspective to stress how individuals impact the course of history. The reader meets elected and unelected public officials, influential folks outside of government, and even several young entrepreneurs with a start-up health insurance company. 93 This people-oriented component pervades Brill’s work.
Notwithstanding the strengths of America’s Bitter Pill, several shortcomings should be mentioned. First, the book is short on both analysis and the requisite context for evaluating the myriad successes and failures that Brill documents. Brill tells a fascinating story, but his default is to recount instead of analyze. Because he fails to develop substantive or conceptually-organized themes, the book is somewhat disjointed. For instance, consider Brill’s descriptions of the multiple occasions in which administration witnesses were evasive in their testimony and responses to lawmakers’ queries. 94 Rather than delving further into this pattern of behavior, Brill discusses each occurrence as an isolated event. Brill’s work contains numerous missed opportunities such as this.
Second, when conducting interviews, the researcher must weigh informants’ potential motivations for their answers, to determine if they are “justifications, embellishments, lies, or selective memories.” Reference King, Keohane and Verba95 But when Brill is star-struck, in awe of his sources’ charisma, passion, or intelligence, he loses objectivity. Take Brill’s portrayal of Liz Fowler, who played a key role in the ACA’s development, as former Chairman Baucus’s chief health counsel on the Senate Finance Committee. Brill devotes over 20 pages to Fowler’s life story, 96 and even dedicates two separate sections—“An Amazing Person” 97 and “A Real Badass” 98 —to her. This loss of perspective diminishes Brill’s credibility on any topic related to Fowler, even his major argument that the PhRMA deal was politically necessary, given Fowler’s integral role in negotiating it.
Third, Brill periodically makes insinuations, posits causal linkages, and draws conclusions without ample evidence and supporting facts. His discussion of Amgen, a large biologics company in California that made campaign contributions to congressional committee members and later won legislative victories in those committees, is symptomatic of this tendency. From 2007–2009, individuals associated with Amgen contributed over $1.1 million to key senators and spent over $38 million on lobbying. 99 And according to Brill, even as a top Amgen official “prowled the halls of the Capitol in July 2009,” the company was being investigated for, and subsequently settled cases regarding, “illegal sales and marketing tactics.” 100 Brill then reports that Amgen won bipartisan victories in two committees and implies that there was a quid pro quo. Yet Brill presents no evidence that members voted contrary to their natural inclinations or their constituents’ wishes. Rather than suggesting the appearance of impropriety, Brill should demonstrate causality. But in the Amgen matter, and others like it, Brill fails to base claims on sufficient evidence.
Fourth, when Brill is promoting an argument, he overlooks information—even information he referenced earlier—when it would undercut his stance. Take Brill’s discussion of “the cliff,” for example. Brill criticizes the Democrats for this “little-noticed quirk in the law,” whereby insurance and out-of-pocket expenses could cost individuals and families “half of their disposable income” if they earn even a dollar more than the cut-off for receiving a subsidy. 101 As Brill acknowledges, not many people would fall over the cliff, although he views it as a looming problem. What Brill leaves out, however, is that the cliff phenomenon is exactly the type of unintended flaw that would be remedied quickly in a less partisan environment through “fix-it” legislation—the normal process of eliminating a new law’s inadvertent consequences (that he previously explained).
Fifth, Brill is prone to hyperbole and editorializing. He writes of being “disappointed at how Obama treated the nitty-gritty details of implementing the law as if actually governing was below the pay grade of Ivy League visionaries.” 102 Brill gripes that he is “disgusted with the government procurement and technology management system that produced the October 1, 2013 version of HealthCare.gov.” 103 And he complains,
[it is] depressing to see that Washington . . . has become so mired in cynicism and red tape that many of the best and brightest refuse to run the gauntlet of working there, or refuse to seek contracts to help the government do its work. 104
Removing such terms as “disappointed,” “disgusted,” and “depressing,” and further substantiating his perspective, would have been more effective.
Emanuel’s nuts and bolts
Ezekiel Emanuel, the author of the third book, emerges as a significant player in Brill’s America’s Bitter Pill. Brill discusses Emanuel in over two dozen separate passages, many spanning several pages. Because Emanuel touts his own role as an inside player and makes himself part of the story in Reinventing American Health Care, Brill’s portrayal of Emanuel’s efforts is relevant. Brill recognizes Emanuel’s academic credentials and intellect but depicts Emanuel as brash, cunning, and self-absorbed. Emanuel was, for instance, “kicked out of the room for arguing too much” when the Democrats were trying to reconcile the House- and Senate-passed reform packages in January 2010. 105 He repeatedly clashed with the Lambrew camp, which was problematic for Emanuel, as Valerie Jarrett (often referred to as the “real chief of staff,” in contrast to Ezekiel Emanuel’s brother Rahm, the nominal chief of staff), 106 aligned herself with Lambrew. Lambrew and Jarrett prioritized extending health insurance coverage over controlling costs. As part of the economic team, Emanuel, on the other hand, concentrated on “bending the cost curve” by addressing health care costs and raising revenue. 107 According to Brill, Emanuel’s group generally lost the internal policy disputes over more cost-cutting provisions. Despite these losses, Emanuel lobbied to head the implementation of health care reform, if the overhaul passed. 108 Not receiving the position, Emanuel left government in 2011.
Reinventing American Health Care examines many of the same issues as Starr’s and Brill’s books, but with different twists and from a different vantage point. At the most basic level, Emanuel sought to fill a void. He realized that “there needed to be a primer on the American health care system” for those interested in trying “to understand the insanely complex system.” 109 In addition, as one of the ACA’s architects, Emanuel wanted to persuade the reader, as his subtitle states, that the law will “improve” our health care system. Emanuel is not a dispassionate observer: he optimistically markets the ACA and inserts himself into the narrative. Furthermore, rather than just offering a retrospective about the health care system and the ACA’s passage, Emanuel explores and even forecasts the future.
Emanuel succeeds in writing a primer about the American health care system that is accessible, clearly written, and well organized. He is, as the expression goes, “like a pig in muck,” when he vividly explains how broken the system was and the necessity of reforming it. More specifically, he expertly details such matters as the system’s structural components, the primary reasons for health insurance, health care financing, payment of providers, and the system’s perverse incentives and major problems. Reinventing American Health Care also effectively encapsulates the dispute over the individual mandate’s constitutionality, the ACA’s myriad parts, how to control health care costs, and so much more. Emanuel is at his best when he presents factual matters and, secondarily, when he offers frameworks for understanding systems and disputes. His charts, tables, diagrams, and lists are informative, and he communicates complex material well using these formats. Review, for instance, the different payment rates for hospitals that he clearly identifies and describes in chapter three. 110 Most notable, however, may be his comprehensive presentation of the ACA’s provisions. 111 Emanuel delivers the most complete overview of the ACA of any of these four books.
The other strength of Emanuel’s work is in his ability to convey both the living legislation perspective and the inevitable unintended consequences of any reform, which he relates to the health care system’s complexity. He highlights and then clarifies the “interrelated and symbiotic” elements of the system, 112 and the impact of the “interconnected weirdness.” 113 Emanuel opines that, “every change or reform will have both positive and negative consequences and also unforeseen consequences. Even dramatic improvements are inevitably going to cause serious dislocation to many other parts of the system.” 114 Because of this complexity, Emanuel writes:
there is no “ideal” system and no final reform
$\ldots .$
Just as one set of policies are expounded and becoming settled, other problems, evasions, and flaws will become clearer, thus necessitating further reforms. Efforts to improve the health care system are inherently Sisyphean.
115
While Emanuel cogently, accurately, and perceptively presents some material, the whole is less than the sum of the parts. First, research problems, such as Emanuel’s virtually complete absence of citations, weaken the overall case. The reader remains clueless about Emanuel’s sources for quotes, facts, figures, and key insights. Without knowing the author’s sources, how can the reader evaluate the author’s claims? For instance, Emanuel rants against the CBO, with its “tyrannical” and “frequently wrong” scoring, along with its tendency “to be cautious” and hence “overestimate costs and underestimate savings.” 116 Emanuel identifies specific CBO estimates on revenues and savings that he contends were inaccurate—with no citations. Given how easily statistics can be used to serve a multitude of purposes, the reader may be unsure whether the CBO’s numbers were, indeed, off. Interestingly, Emanuel later backpedals regarding his vociferous opposition to CBO scoring and touts CBO estimates (again with no citations), when he perceives them to be in support of his position. 117 Similarly, when he describes how the economic team (on which he served) clashed with other governmental players, the reader should be able to consult references to verify Emanuel’s depictions of his opponents’ stances. 118
Second, Emanuel is prone to making misleading characterizations. Take, for example, his attempt to downplay the degree to which the ACA concentrates on access and universal coverage, which were not his primary focus at the OMB. Emanuel states as evidence that if “you count the pages, under a quarter of the bill can be said to be about access.” 119 That argument, however, is a red herring and disingenuous—the number of pages devoted to a subject is neither tantamount to the issue’s significance within the measure’s framework nor particularly informative about the extent to which the law modifies the status quo in that area.
Third, Emanuel has a penchant to overstate virtues and minimize vices when he is favorably inclined, and vice versa when he dislikes something. Consider the chapter—“What Does the ACA Mean for Me?”—in which Emanuel claims that, “for the majority of Americans the ACA constitutes a big improvement.” 120 At the chapter’s end he includes a short subsection entitled “Caveat.” Rather than acknowledge that “there is a very real chance” that his “view [regarding the ACA] is overly positive” when he presents his “view” as a fact, he relegates a discussion of “what could go wrong” to a few paragraphs many pages later. 121 And Emanuel’s exploration of “what could go wrong” does not scratch the surface of the ACA’s potential problems; in fact, some items that Emanuel contends “are guaranteed to get better for all Americans because of the ACA,” 122 may have consequential downsides. One can question, for instance, his inclusion of the electronic health record (EHR) system as a definitive benefit. Providers and patients, in particular, may not deem EHRs an improvement. They now have less time for meaningful communication, as doctors and nurses must spend time focusing on their workstations and laptops instead of on their patients. Although EHRs may furnish up-to-date patient information, the fixation on electronic record-keeping may yield worse health outcomes and compromised provider-patient relationships. Furthermore, patients may worry about the loss of privacy with EHRs. Note, as well, that although Emanuel lists EHRs as improving medical care “for all Americans because of the ACA,” 123 this contradicts Emanuel’s other statements that correctly attribute EHRs to The Recovery Act of 2009, and not to the ACA. 124
Fourth, along the same lines, Reinventing American Health Care suffers from an array of factual errors. I focus here on one misinterpretation, which is symptomatic of the types of shortcomings that exist. Emanuel contends that when health care reform appeared to be nearly dead after Scott Brown’s January 2010 victory in the Massachusetts special senatorial election, President Obama resuscitated it. According to Emanuel, President Obama—through his repeated declarations that the Wellpoint health insurance company’s rate hikes for California customers showed the necessity for reform—“persuaded the House to embrace the idea that after 14 months of work and the potential for a major legislative achievement, having no reform bill would be worse than enacting the imperfect Senate health care reform bill.” 125 In solely crediting President Obama for the ACA’s passage, Emanuel over-simplifies what transpired: he ignores Pelosi’s work and her adroit wielding of the speaker’s baton; Reference Budoff and Thrush126 he further overlooks Democratic legislators’ growing fear of inaction due to polls showing that despite Americans’ qualms about reform, dropping it would trigger “frustration,” “disappointment,” and “anger” among the electorate; 127 and, he neglects how the Democratic congressional leadership skillfully employed reconciliation to enact health care reform when Democrats lost their filibuster-proof super-majority. 128
Fifth, Emanuel’s role in the Obama administration undoubtedly contributed to the book’s pronounced executive-centered orientation. Note the example just discussed, in which Emanuel inflated President Obama’s role in the ACA’s enactment. A more superficial manifestation of this bias emerges with Emanuel’s introduction of executive branch staff, while leaving congressional staff nameless. Most consequentially, Emanuel’s concentration on the executive branch facilitated the production of a book too focused on himself, the issues he worked on, and his discontent with some of what occurred. Witness the three cases Emanuel selects to “illustrate the complex interplay between policy, politics, and interest groups.” 129 Instead of exploring the most controversial or substantively significant subjects regarding the ACA’s passage, Emanuel writes about certain topics because he “was engaged on these issues” at the OMB. 130 His examination of the tax exclusion and “Cadillac tax” on high-end insurance plans then morphs into a review of Emanuel’s significant influence (in his own eyes): he seized “the opportunity [in a meeting with President Obama] to argue for altering the tax exclusion”; 131 he then presented the notion that the president had not previously heard, that “the tax exclusion was the single-most effective instrument the president possessed to control and reduce private-sector health costs”; 132 and, ultimately he articulated the “good policy rationales in favor of cost control—not revenue generation—[that] overcame the president’s past statements.” 133 Emanuel concludes, again without providing any citations or evidence, that the Cadillac tax he promoted has started achieving its objective even prior to implementation as insurers and employers proactively take action to avoid the tax. In addition, knowing Emanuel’s desire to head the ACA’s implementation, one wonders whether his harping on the ACA’s flawed roll-out as a “managerial” problem is a fair characterization or just sour grapes.
The last limitation meriting attention appears at the book’s end, where Emanuel extrapolates from the ACA’s provisions to a starkly different future with a transformed health care system. Based on his “optimism,” as well perhaps as a significant dose of wishful thinking, Emanuel posits the end of health insurance as we know it, prioritization for care of the chronically and mentally ill, the cessation of health care inflation, technology’s eventual replacement of hospital stays and specialists, closure of large numbers of hospitals, private-sector employers relinquishing their role of providing health insurance, and transformed medical education. Wow! Given Emanuel’s earlier persuasive historical narrative about how external forces stymie meaningful reform, 134 and the necessary confluence of no fewer than six preconditions for enacting reform, 135 I was befuddled by Emanuel’s disregard for his own arguments.
Davidson’s concise contribution
A New Era in U.S. Health Care by Stephen Davidson complements the previous three books reviewed in this essay, offering a succinct accounting of the health care system and the ACA. Davidson explains the problems with the health care system prior to the ACA’s passage and how the law has ameliorated some of these weaknesses, but not others. Unlike the other volumes, Davidson’s analysis focuses more on clinical determinations (primarily by physicians) that impact health care utilization patterns and consequently can address shortcomings related to access to services, cost containment, and quality of care. Similar to Starr, Davidson’s work builds on his own earlier study of the health care system. Reference Davidson136 Using that as a foundation, Davidson’s main purpose in this book is to consider the health care system’s future.
Several strengths of A New Era in U.S. Health Care deserve recognition. First, with incisive brevity, Davidson illuminates and unpacks complex, critical concepts. He delineates the system’s problems of access, cost, and quality from individual and aggregate perspectives, and from the provider perspective as well. Davidson also juxtaposes the complicated web of interrelated ACA provisions with the system’s pre-existing shortcomings. And he deftly gleans the core issues regarding the law’s constitutional challenges. 137 Overall, Davidson clearly conveys his judgment regarding the benefits of universal health insurance 138 and carefully articulates his belief that the ACA fails to tackle problems in the most straightforward, vigorous manner possible, e.g., by creating a single national health insurance program for everyone, by designing a system that would not require extensive regulation, and by altering how providers are paid to incentivize them to address spending and quality problems. 139
Furthermore, as mentioned, Davidson contributes to the discourse regarding the health care system and the ACA by more fully exploring providers’ perspectives. He considers such topics as providers’ financial pressures, the connections between utilization decisions on the one hand and cost containment and quality improvement on the other, the competing influences affecting how doctors care for their patients, the impact of payment incentives (whereby clinicians may prioritize their financial interests over patient interests), and how the system rewards providers’ inefficiencies (e.g., with providers earning money for supplying unnecessary services). 140 Davidson’s experience on a small health center’s board may have inspired his provider-centered perspective. For according to Davidson, he witnessed the “untenable situation” of a perverse payment structure, with individuals lacking insurance paying about 90 percent of the center’s charges, whereas those insured by Blue Cross/Blue Shield paid about 75 percent and United Healthcare and Medicaid recipients paid about 65 percent. 141
Another noteworthy feature of Davidson’s book is that, like Brill’s work, it recognizes that states will help determine the law’s accomplishments. In contrast to Brill’s focus on Kentucky as a case study, though, Davidson provides a macro-level examination of this delegated governance pattern. In particular, he delves into the effect of the ACA’s reliance on Medicaid for achieving its coverage expansion objectives. Davidson sheds light on such critical issues as the following: pre-ACA Medicaid inter-state differences; how the reliance on state governments’ individual decisions undermines the development of “stable, uniform national coverage”; 142 and the consequences of such diverse factors as state wealth, Medicaid eligibility criteria, capacity to pay Medicaid expenditures, attitudes toward the poor, geographic location, administrative capacity, political interests, and medical care costs. 143 Because poorer states tended to lag in Medicaid enrollments pre-ACA, Davidson stresses that they have a larger proportion of adults who would benefit from the ACA’s Medicaid expansion provisions. 144
Without employing the living legislation jargon, Davidson also accurately conveys the centrality of this conceptual prism. He underscores that the ACA’s “outcome is not a foregone conclusion . . . because it depends on so many actions yet to be taken by a host of different actors.” 145 Davidson’s argument that the ACA’s accomplishments depend on the efficacious utilization of opportunities—by myriad people in the executive branch, members of Congress, state officials, clinicians, health care delivery organization leaders, and individuals—is important and well communicated.
Finally, Davidson clearly develops another of his major arguments, namely, that “the ACA may not be ideal,” but because it provides “tools for creating substantial progress” on access, cost, and quality issues, “the rational choice is to make the best of the ACA.” 146 This pragmatic approach flows from and complements Davidson’s historical review of attempts to pass reform, suggesting that “it is exceedingly unlikely that a better law could be passed any time soon.” 147
Alongside these strengths, A New Era in U.S. Health Care has shortcomings, too. Most significantly, portions of the book are dated and dead wrong, especially in Davidson’s analysis of upcoming challenges or, as his subtitle states, Critical Next Steps in U.S. Health Care. Take his discussion about state health insurance exchanges. Davidson opines, “Since lots of money will be at stake, it can be expected that health insurers and other stakeholders in each state will try to influence the decisions that will result in a functioning HIX [health insurance exchange].” 148 Given that most states are utilizing the federal exchange, not their own state exchanges, Davidson miscalculated here. Contrary to his claim that “one of the first decisions a state’s legislature must make is how to organize its exchange,” 149 the first choice actually is whether to establish an exchange. Thus, Davidson’s subsequent examination of the factors that states should consider when creating their exchanges is largely moot, since most states ceded authority to the federal government. 150 In addition, his framing of another major challenge—“the importance of implementation of the law’s provisions as illustrated by the battle over the Medical Loss Ratio [MLR]” 151 —is odd. All four challenges he identifies pertain to “implementation of the law’s provisions”; hence, why single out implementation as its own barrier and then focus on the MLR? 152 The MLR regulations also were neither significant nor controversial enough to merit four pages in a brief book.
A New Era in U.S. Health Care contains numerous factual errors and misleading statements, as well. For instance, Davidson incorrectly identifies the ACA as PL 111-148. As noted above, PL 111-148 is the PPACA, which along with the HCERA, PL 111-152, comprises the ACA. Moreover, when Davidson initially addresses the ACA’s Medicaid expansion provisions, 153 he does not indicate that many states opted not to participate, therefore leaving the reader with an incorrect impression that all states will increase Medicaid eligibility. And he fails to rectify this inaccuracy until about 15 pages later. 154 Davidson misrepresents what transpired, too, when he writes that budget reconciliation “gave considerable leverage to several Democratic senators on the more conservative end of the political spectrum, which they used to extract concessions that would benefit their home states.” 155 In fact, the conservative Senate Democrats won concessions from then-Senate Majority Leader Harry Reid (D-NV), such as former Senator Nelson’s “Cornhusker Kickback” and former Senator Mary Landrieu’s (D-LA) “Louisiana Purchase,” when Reid needed all 60 Democrats to support the PPACA to pass it in December 2009. But as soon as Reid simply had to muster 51 votes for the HCERA under budget reconciliation, the conservative Democratic senators’ leverage disappeared. 156
A telling difference
A reader of any one of these books will learn a significant amount regarding the American health care system, health care reform efforts, and the ACA. Examined together, the books’ similarities further inform readers about issues for which notable consensus exists. While the authors each unequivocally stress or demonstrate the ACA’s complexity, however, they highlight different ACA components, offer distinct characterizations of the law, and utilize divergent approaches for appreciating its content. In other words, the ACA is such an intricate, multifaceted conglomeration of programs, policies, regulations, mandates, and subsidies that each book offers unique insights regarding the law or new perspectives through which it can be understood. Thus, indirectly, through their varied emphases, the books also illustrate the ACA’s complicated nature.
Starr contends that the “great sacrifice” in the ACA was in enacting such a complex law, attempting to mesh our health care system’s economic, political, and even psychological complexity. 157 He underscores that the complicated ACA represents an “ambitious effort,” but also acknowledges that it is “comparatively limited” when considered alongside other democracies’ health care systems or liberals’ “ideal remedies.” 158 Rather than systematically detailing the law’s myriad and entangled provisions, Starr explores its components through what he deems “the central problems of public philosophy: fairness and finance, responsibility and freedom, federalism and finance, and the scope of concern for health and health care in the public household.” 159 In examining the key ACA provisions through these theoretical lenses, Starr provides a conceptual framework for understanding the ACA, which is not imparted by the other authors.
Brill, similarly, does not systematically summarize what he describes as “the mind-numbing complexity of the furiously lobbied final text of the legislation.” 160 Instead, the reader learns about the ACA’s provisions through Brill’s discussions, stories, and vignettes about relevant actors (e.g., elected and unelected officials, moneyed interests, consumers, bureaucrats, and entrepreneurs trying to form a start-up health insurance company), about what transpired (e.g., the political and ideological battles preceding the ACA’s passage, the legal fights after enactment, and the challenges of implementation), and more. Brill focuses most heavily on the insurance exchanges and Medicaid expansion, but also explains a multitude of the law’s elements, such as those regarding cost control, quality improvement, prevention, and revenue. Perhaps inadvertently, Brill’s scattered and disjointed presentation of the ACA’s content only reinforces the sense that the ACA is a confusing hodge-podge of innumerable pieces.
Emanuel offers the most comprehensive, organized overview of the ACA’s provisions. Not only does he detail and furnish synopses of each of the law’s sections, he also explains the ACA’s substance thematically, as well. Emanuel’s chapter on the ACA’s content does not explicitly underscore the law’s convolutions, as his objective is to make it comprehensible. In fact, after stressing how complicated the health care system is, Emanuel describes the ACA’s diverse and confusing features in an uncharacteristically muted manner:
The ACA is certainly more complex than the only other very large-scale health reform ever attempted in the United States: Medicare and Medicaid
$\ldots .$
By reforming what already existed and then adding new programs on top of that, the ACA became necessarily more complex than simply creating a new health insurance program de novo.
161
Nonetheless, Emanuel’s straightforward explanation of the ACA’s provisions cannot disguise the law’s inherent complications. What stands out from his effort to unpack the ACA is just how entangled the law’s provisions are and how much the law contains.
Davidson, in contrast, directly emphasizes the ACA’s complexity. Moreover, the law’s breadth and complicated nature emerge indirectly by comparing Davidson’s work with the other books. In A New Era in U.S. Health Care, one learns about ACA elements that are not explored in much longer publications. Davidson details the workings of Accountable Care Organizations (ACOs), for instance, devoting about 10 percent of his book to these networks of diverse providers that assume clinical and financial responsibility for patient care, whereas Starr, Brill, and Emanuel barely mention ACOs. Similarly, in his examination of cost containment efforts, unlike the other writers, Davidson highlights the Independent Payment Advisory Board (IPAB), a 15-member organization that the ACA creates to submit proposals regarding how to decrease the per capita Medicare growth rate. 162 (Note, however, that the IPAB has yet to be formed. Reference Zigmond163 ) And as mentioned, Davidson delves into MLRs, which draw scant attention from others.
Conclusion
In summary, each of these books offers something valuable. If you want an historical analysis of the U.S. health care system conundrum up until the time of the ACA’s passage, then Starr’s Remedy and Reaction is the right choice. For a lighter, yet still engaging and informative discussion of the health care system and the ACA, Brill’s work makes sense. Emanuel’s Reinventing American Health Care, on the other hand, provides a nuts and bolts primer on the health care system and the ACA that is denser than Brill’s book. But both Brill and Emanuel commendably make health policy accessible to a wide audience. Finally, if you only have a little time to devote to the study of health care policy, read just the first half of Davidson’s work, before he turns to what he deems to be the law’s future challenges.
Both individually and as a group, these four titles should provide the basis for fruitful discussions. Bearing in mind the authors’ varying orientations, backgrounds, objectives, and biases, readers might juxtapose these writers’ perspectives on the health care system and the ACA with unfolding ACA implementation developments, which are ongoing. Interesting conversations, undoubtedly, will ensue.
Note
For their helpful comments and suggestions on earlier drafts of this essay, I would like to thank Erik Bucy, Ginny Roberts, Lori Sonken, and George Young.
