For decades the key question in political science, sociology, and history about U.S. health care has been a simple one: Why doesn’t the United States have universal health coverage (Hoffman Reference Hoffman2006)? The answers, in various combinations, are by now well-rehearsed: racism, interest groups, veto points, and path dependency. A second generation of analyses, however, has come about with a different basic question: why is American public policy so complex, and what are the effects of that complexity? The “hidden welfare state” (Mettler Reference Mettler2011), or “delegated welfare state” (Morgan and Campbell Reference Morgan and Campbell2011), or “kludgeocracy” (Teles Reference Teles2012) are three takes on an American model in which private actors are built into a needlessly elaborate welfare state. This allows them to engage in rent-seeking activity and also disguises the public nature of most benefits received by the middle class. The effects are pernicious. This model produces complexity, rewards lobbying, distorts understanding of the U.S. welfare state, and creates new political battlefields.
Much of the Affordable Care Act (ACA), especially its elaborate insurance markets, epitomizes this kind of policymaking. It is a triumph of political technique but the result looks as if Democrats intentionally designed a law for which they wouldn’t be able to reap credit. As a result, health care is an excellent place to understand the politics, effects, and likely persistence of the United States’ tendency to extremely elaborate social policy. The three books under review here are all interesting and important contributions to answering the question of why American public policy is so very complex, with implications for scholarly research as well as for political action.
Daniel Béland, Philip Rocco, and Alex Waddan’s Obamacare Wars exploits the complexity and size of the ACA to conduct what is essentially a within-law comparison. This allows them to go beyond the simple story of partisanship. Some parts of the ACA became the sites of heated battles within American politics while others were enacted and implemented with little fuss. Why? To answer this, they examine the level and kind of conflict found regarding its health insurance exchanges, Medicaid expansion, and changes to health care regulation. Their answer (pp. 30–35) is that three factors explain varying levels of contestation: policy legacies, “institutional fragmentation” (which means federalism), and public opinion (which is taken as an exogenous factor despite literature on how partisan elites cue opinion).
Thus, the health insurance exchanges were thinly institutionalized, and very different even in the few states that had them (e.g., Utah and Massachusetts). Their creation required positive state action, typically legislation, which gave opponents an opportunity to fight at the state level. And they had little support in public opinion, in large part because few people knew what they were. Add in that the default penalty for states that built no exchange was just inclusion in a federal exchange, and the result was the perfect issue for anti-Obamacare position-taking by state politicians (see Jones Reference Jones2017). At the other extreme, health insurance regulations were popular, were deeply institutionalized, and didn’t require positive state legislative action (in part because, as Béland, Rocco, and Waddan show, state insurance commissioners and the Obama administration went to lengths to make it so). Medicaid expansion, which the Supreme Court rewrote to make optional in a decision the authors treat as exogenous, falls in the middle.
Every method has its drawbacks as well as its advantages. The authors’ within-law comparative method means that the authors downplay some rather big issues that shaped the whole ACA: partisanship, race, and the internal politics of the parties. Yet while partisanship keeps creeping back into the argument, race as a topic in federalism only appears when the authors reference President Obama discussing it (p. 93). That is an unusual lack of emphasis, given that most of the consequential history of federalism in the United States has to do with race. The ACA was an unusually partisan (Morone Reference Morone2016) and racialized (Tesler Reference Tesler2011) law, but that shows up better in contrast to other laws or American political history rather than in a within-law contrast between Medical Loss Ratio definitions and Medicaid adoption.
The ACA actually incorporated some pretty good political science, and this book helps us to see what political science might in turn take away from the ACA. Overall, the ACA could be regarded as operating on the hypothesis that American politics is essentially transactional, and money is indeed a constant topic in Obamacare Wars. For example, the clear hypothesis in the ACA is that states try to maximize their money and secondarily their autonomy. That is a common enough assumption in comparative federalism and it creates obvious incentives to cooperation for those interested in state budgets, major economic interests such as hospitals, and credit-claiming politicians. During passage, members of Congress acted as if that were their hypothesis as well. They supported or opposed decentralization to states based on whether they thought the White House or their state were more likely to be in their party’s hands (McCann Reference McCann2016). The Medicaid expansion was a very nice intergovernmental offer for the states. The exchanges allowed states to tailor health insurance market decisions such as whether to be an active purchaser to local politics, which governors could be expected to appreciate. Yet the result was not happy states but rather trench warfare. The explanation for that lies in parties and partisanship but the terrain is explained by the three factors the authors emphasize.
The ACA is part of an essentially transactionalist view of American politics that has long been established in the discipline and the minds of many Democrats. The transactionalist view has, however, become increasingly inaccurate (Hacker and Pierson Reference Hacker and Pierson2014) as a picture of a Republican party in which ideology (Grossmann and Hopkins Reference Grossmann and Hopkins2016) and powerful networks (e.g., the American Legislative Exchange Council and Fox News), run by a few people, hold more sway than many established interests (Hertel-Fernandez, Skocpol, and Lynch Reference Hertel-Fernandez, Skocpol and Lynch2016). In this environment, “ordinary” interest group politics as a whole often lose out to these ideological networks, and what appear to be ordinary interest groups aren’t. The authors, for example, treat the National Federation of Independent Business (NFIB) as a voice of “small businesses,” which might in principle represent negotiable material interests. The NFIB could be better viewed as a militant part of the Republican party with members from among small businesses (Young Reference Young2010).
Obamacare Wars might be the guide to policy in a new world of polarized, racialized politics where at least one of our two political parties seems not to have read classical political science about coalitions and interests. Reliance on thick policy legacies, strong public support, and simplicity might suggest the way forward for new social policy initiatives in the United States. In other words, it points to “Medicare for all.”
Keeping things simple might be a newly pressing policy imperative, as my reading of Obamacare Wars suggests, but there are still compelling reasons why the United States federal government is so bad at doing so. That is the topic of Robert Saldin’s lovely When Bad Policy Makes Good Politics. This short book goes deeper into just how the Democrats managed to write such a complex law. It focuses on the mystery of the Community Living Assistance Supports and Services (CLASS) Act, a title in the ACA that would have created a generous long-term care insurance program. The CLASS Act would have been a voluntary insurance program, open to everybody, with a five-year vesting period, low premiums, and relatively generous benefits for long-term care accessible by the elderly or disabled. In other words, it would have addressed a major social problem but would have been fiscally unsustainable. Its voluntary nature would have forced it into an “insurance death spiral” of adverse selection in which people would likely have only started to contribute when they saw a need for it coming.
It is quite remarkable that such a transformative change to the U.S. welfare state as the CLASS Act could have first been passed and subsequently axed with so little discussion in political science, but that is the case. That is the political science version of a larger problem Saldin notes. While health care is a heavily researched area, disability and ageing policies are not. Policymakers were therefore essentially flying blind as they designed CLASS. The intersection of this ignorance about the likely effects of their policy with a set of technocratic budget rules and the happenstance of politics drives the narrative of Saldin’s book and explains CLASS. Advocates’ most useful learning was not about how to set up an effective and sustainable program. It was rather “political learning” about how to get a policy through the federal government (pp. 14–15). Some of that is the nature of getting things done in national politics, but too much of it produces the kinds of problems Saldin describes.
The CLASS Act, which was not sustainable in its legislative form, got into the ACA because its five-year vesting period made the ACA cost less over ten years under Congressional Budget Office (CBO) rules. In an interesting episode, Republican Senator Judd Gregg’s amendment to make the Secretary of Health and Human Services responsible for certifying the sustainability of CLASS before starting it up was accepted. That meant the CLASS Act, so big and potentially transformative, died in a letter from Secretary Kathleen Sebelius that declared it fiscally unsustainable. Saldin is clear about what remains mysterious (e.g. just what Gregg was thinking or whether the Obama administration ever really cared about CLASS). But in his reading, the CLASS Act did its job of helping Democrats game CBO rules, and Gregg’s amendment allowed them to euthanize it more quietly afterward.
As Andrea Louise Campbell quips on the back of the book, “Come for the story of long-term care reform, stay for the critique of CBO scoring!” Saldin does not just tell the story of the CLASS Act. He uses it to tell the story of a frustrated revolution in budgeting, in which the central role of key House and Senate committees in ensuring budget balance was replaced by a technocratic model built around the CBO’s ten-year scores. The “fiscalization” of policy resulted, in which policy after policy was designed to reduce the budget over ten years, both for optics and in order to use Senate reconciliation rules. The George W. Bush tax cuts, the Trump tax cuts of 2017, and to some extent the ACA all relied on reconciliation, which in turn relied on gaming the CBO with tax changes that start and stop on weird schedules.
Of course, accepting the Gregg amendment was technocratic policymaking in its own right. Democrats could have learned from the George W. Bush tax cuts, passed something that was obviously popular but unsustainable, and dared future policymakers to undo it. That would have made a very interesting case for political scientists to study. It might also be a reasonable picture of the future. This particular set of budgetary dysfunctions might not continue to shape policy if the Senate continues to edge towards majoritarianism (Reynolds Reference Reynolds2017) or Democrats, looking upon the 2017 tax bill, conclude that deficit-cutting politics are not good politics.
Both Obamacare Wars and When Bad Policy Makes Good Politics are strongly institutionalist, focusing on the impact of institutions and legislative design. That includes the effects of CBO scores, numbers that are socially constructed (the scoring rules could be otherwise) but are also formally and politically powerful. Not everybody is convinced about the benefits of this fiscalizing institutional arrangement with economists at the center. “Hush the economists” was “the most heretical” of Morone and Blumenthal’s rules for effective health reform (Blumenthal and Morone Reference Blumenthal and Morone2009): “Expanding health coverage requires presidents who are willing and able to override their economic advisors. Getting healthcare to large populations is expensive; economists invariably oppose it” (p.413). (To be fair to economists, the problem is as often budgeters as economists; White Reference White2013).
These two books provide some solid support for Blumenthal and Morone’s rule. When Bad Policy Makes Good Politics is about the strange effects of a legislative process that empowers rather than hushes “economists” and makes everything into a policy about the deficit. The fiscalization of policy produced this half-baked insurance program, even if a series of legislative accidents explains its particular unworkable form. Obamacare Wars is about the conflict engendered by elements of a law that were largely created to satisfy economic projections. For example, the authors note that institutional fragmentation can be cheaper than a federal program because a federal-state program can call upon state governments for administrative resources (p. 19). The ACA was unusually satisfying to economists and looked good under CBO rules, in part because that was a prime objective of its authors, but as both books show, the result was a set of policies that were much more complex and ambiguous than they really needed to be. A quick look at other health systems of the world will, of course, demonstrate the same thing—the United States’ delegated, hidden, kludgeocratic health sector is far more complex, and expensive, than it would be in a different political system with fewer veto points. Empowering economists might not be the reason for this complexity, but it clearly hasn’t remedied it.
A comparative view also highlights something else about the United States, which is the topic of Daniel Sledge’s Health Divided. Alongside the much-lamented U.S. health care industry stands a much-admired U.S. public health establishment. Sledge poses the excellent question: how is it that the United States managed to build such a strong, federal, public health infrastructure at the same time as it failed to develop anything like a coherent federal approach to health care coverage (p. 2)? He compares the development of the U.S. public health infrastructure, starting with the Marine Hospital Service establishment in 1798, to the development of health care insurance up to World War II. The Marine Hospital Service became the Public Health Service (PHS), still in existence today though largely unknown. The PHS was one of the first federal social-policy initiatives and was the center of American federal health policy for almost two centuries. It is a uniformed military-style corps led by the Surgeon General with major responsibilities including quarantine, medical care for sailors, and, over time, communicable disease control and medical research. Nowadays, those two last parts are known as the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), both very effective and immensely influential as international models (Carpenter Reference Carpenter2010, Greer Reference Greer2012). Sledge, almost uniquely among political scientists or historians, takes the PHS and its actors seriously, and that alone means this book should be read by anybody who wants to understand the development of American health politics.
History through this lens is fascinating. Theda Skocpol and others have taught us about the importance of the 1921 Sheppard-Towner Act and the Childrens’ Bureau in the Department of Labor in moving the United States down a maternalist welfare trajectory (Skocpol Reference Skocpol1992). However, we rarely hear about the opposition to this from the PHS (pp. 78–79). Likewise, the extent to which plans for insurance reform and reform of health care delivery were always linked is important. It is a salutary reminder that today’s advocates of integration and prevention are channeling century-old ideas (Emanuel Reference Emanuel2017). It is also a salutary reminder that it is often easier to persuade doctors to expand coverage than to meddle in their practice.
In Sledge’s narrative, war also gains a prominence that it does not always have in health policy history, including because of the extended bureaucratic capabilities and prestige it creates. We learn a lot about the critical juncture under Franklin Delano Roosevelt when Surgeon General Thomas Parran and the American Medical Association (AMA) started to approach a compromise on health insurance. Had they done so, it could have changed American history by creating a large-scale public program before World War II triggered the processes which led to reliance on employer-provided health care. Social Security officials such as Isidore Falk, who are usually presented as heroes of American welfare state development, here are cast as purists whose dedication to universal social insurance means that they lost the opportunity to start building a program resembling those of Western Europe. They critiqued the PHS for being too close to the American Medical Association (AMA), when the PHS leadership was also arguing for efforts to integrate public health and individual medicine in ways that were far more progressive than the AMA. Even the AMA, hobgoblin of the literature, looks more reasonable when we see it through Parran’s correspondence.
Sledge also highlights the influence of political sectionalism in America. Politicians from the South could occasionally be prickly about having issues like pellagra publicized by the federal government (pp. 76–77). But overall, they were in favor of federal action on communicable diseases for the best of economic reasons: pellagra (a disease of dietary deficiency), hookworm, malaria, and yellow fever are all bad for the economy. Federal assistance in coping with them, particularly in the form of expertise and small co-financing for county health departments, was quite welcome and probably explains both the similarities and the diversity of county public health departments to this day. The racial logic used is about what could be expected from many white southerners in the early twentieth century, with blacks cast in the same role as vermin—as a “reservoir” of disease (p. 7). The political logic of seeking federal assistance that would boost the economy without undermining white supremacy was also typical enough. As historian James Giesen points out, the Mississippi Delta’s cotton economy was best viewed as a labor control system (Giesen Reference Giesen2012). A certain amount of public health is good for such a system, and sharecroppers lacked the resources to produce their own public health. Northern politicians, meanwhile, were not easily convinced of the merits of sending their money south when they had already built effective public health infrastructures in their cities and states (p. 71). The discussion of sectionalism is mostly located in the discussion of public health prior to the New Deal, but it is worth reflecting on its explanatory power both during the New Deal and after. The weakest public health infrastructures, the worst public health threats, and the greatest reliance on the federal government for public health assistance continue to be centered in the states of the old Confederacy.
The book’s main problem is that the discussion of health insurance manages to steal even this show. Rather than a comparison of public health (successful) and health insurance policy (unsuccessful), the book is a story of the rise and decline of the PHS’ influence on health care. The predecessors of the CDC and NIH (and for that matter, the marine hospitals) get very little attention as compared to the debates about health insurance. Communicable disease control gets the most attention, primarily as Sledge tracks the way the PHS began to move inland from its quarantine stations and develop federal power and prestige by its effective actions. In a virtuoso bit of historical epidemiology tucked into Chapter 6 (pp. 128–129), he even demonstrates the mortality reductions caused by PHS assistance to individual counties in the south. Once the New Deal gets going, however, the book’s focus shifts to health insurance. The NIH and CDC (and the unmentioned FDA) continued to grow in prestige and budgets, even if Surgeon General Thomas Parran’s compromise with the AMA was lost to history. The United States has shown a recurrent tendency to face clear public policy challenges such as uninsurance and ill health, shy away from addressing them for political reasons that are well known, and then compensate the losing advocates with a mixture of targeted programs (e.g., the CDC or the Hill-Burton hospital subsidy program), research (e.g., the NIH), and regulation (e.g., the FDA). From this perspective, the fate of the PHS is all too American.
In comparative terms, Sledge’s book is the one that has the most potential to initiate a conversation with other countries. One of the striking facts about public health is just how much it varies internationally. Below a thin, technical, and normative Anglophone literature about best practices there is spectacular variation in who does what, and with what expertise, resources, territorial coverage, legal authority, and stature. The production of public health as a concept, let alone one with normative, political, and bureaucratic implications, let alone in comparative perspective, is almost wholly unstudied outside medical history (though see Weimer and de Ruijter Reference Weimer and de Ruijter2017). More dialogue between comparative politics, health politics, history, and the field of Science and Technology Studies might be extremely useful in pursuing the direction Sledge has shown. In the same vein, Saldin’s comments—on how policymaking works differently when there is no data— point to the gap between policy analysts, obsessed with data, and theories of the political process that often downplay the practicality of a policy as a factor.
All three of these monographs are, finally, good demonstrations of why books are so valuable (though all three have curiously poor indexes and could do with sections about their qualitative methods). None of these arguments could be convincing in article length; there would be no room for the necessary expertise or research. Without books, hypotheses as interesting and important as those adduced and argued in the three books considered here would just not be in the literature. As a result political science, as well as American debates about health, would be the worse off.
