Inside National Health Reform

"This is really two books in one. John McDonough is an insider. He was an adviser to Senator [Ted] Kennedy’s HELP committee, which was one of the two big committees in the Senate that wrote the health reform law. He was in a lot of meetings, talked to a lot of people, and tells wonderful stories about negotiations over the minutiae of the health law. It’s suspenseful and interesting to see how law, and this law in particular, is really made. There’s a lot about the politics but it also explains the policy rationale – why it was structured this way, why one side thought this and the other side thought something else. That’s the first half of the book, and it’s not a hard read. The second half goes through the law in summary fashion, through each title and then each sub-section. It explains what they’re about and why, and how much money they cost or save, in plain language. That in itself, I will admit, is pretty tedious. I’ve read the law and summaries of it, and it’s not fun. You only do it if you are looking for something. However, he intersperses long passages explaining more of the politics and policy rationale. Those chunks are easy to pick out by eye, so you can just flip through the summary of the law and go straight to the narrative. It’s just as intriguing as the first half of the book. This book is important because most people have no idea how laws are really made in the US, and what politics really means. Not the politics of campaigns but the politics of making a law, especially one as complicated and controversial as the health reform law. In the end, the message is that the health reform law we got in 2010 was the only one we could have got in 2010, or pretty close to the only one. The range of what was politically feasible was incredibly narrow. It had to satisfy so many political constraints that it almost didn’t happen. It was either that law or no law. No law is perfect. No law will satisfy everybody. My view is that the correct interpretation of what we have is not the national health reform we all deserve and want, but a good first step towards an evolutionary reform. There will need to be more. We can build on what we have. But the status quo was not and is not acceptable, and this makes some important changes. The reforms to the health insurance market were absolutely crucial and, abstracting from the law itself, relatively uncontroversial. Across the political spectrum, it would be hard to find many people who would say, “Actually, it’s a good thing that private insurers can keep people off insurance. They should be able to keep people off, they should be able to throw people off, and it should be very expensive.” In reforming the way that market functions, the law logically requires some other things that are controversial, but that principle alone is one of the best aspects. It will not have a substantial impact on most people who are currently insured. It is possible, depending on where you work, what your employer does and what your future holds, that you will be impacted. If you lose your health insurance for whatever reason, for example, there will be better options for you beginning in 2014. And there are some aspects of the law that will change features of your health insurance – some things you may like, some things you may not – but in relatively minor ways. Oh yes. It’s very expensive and very hard. It’s a difficult market because it lacks the kind of rules that are required to make it function well. Those rules are in the law now."