Book Review: Inside National Health Reform, by Dr. John E. McDonough, DPH, MPA, California/Milbank. Books on Health and the Public, 2011, 339 pages, $28

September 22, 2011 - This is the inside story, written by a quintessential Democratic insider, on how the Affordable Care Act, the Health Reform Law passed on March 23, 2011, came to be.

Its author, John E. McDonough, is a proud Democratic (“I was baptized a Democrat”). He was also a Democratic legislator in Massachusetts and is now an academic at Hunter College in New York City. McDonough dedicates his book to the late Senator Edward Kennedy.

As a professor at the Harvard School of Public Health, McDonough served as Senior Adviser on National Health Reform for the U.S. Senate on National Health Reform, and helped create and craft the 2006 Massachusetts health reform law.

No Apologies

There are no apologies there. McDonough is immensely proud of the health reform law. He is giddy about its accomplishments, even its warts and blemishes (“The ACA is a product of naked and enormous self-interest and an act of public-interest legislative politics of the highest order... a huge experiment that will harm or burden the lives of many, many Americans...On balance, in my view, the advantages and benefits of the law vastly outweigh the disadvantages and harm.”). He says the health reform law would not have been possible without Romney care, which showed reform was doable.

He is proud of the legislative shenanigans it took to get the law passed, of the legislative bribes (“The Cornhusker Kickback” and “Louisiana Purchase” to Nebraska and Louisiana Senators required to get their votes), of the roles played by Nancy Pelosi and Harry Reid in passing a partisan law against unanimous Republican opposition (Pelosiis quoted as saying,”We will go through the gate. If the gate is closed, we will go over the gate. If the fence is too high, we will pole-vault in. If that doesn’t work, we will parachute in. But we are going to get health reform passed.”)

McDonough’s heroes are Senator Kennedy, who kept alive the torch of national health reform for 40 years, and Pelosi and Reid, who kept its flames flickering, when they were threatened to be extinguished at critical legislative moments.

Virtues of Political Will

To McDonough, passage of the health reform law was an act of “sheer political will.” It was worth any price, any behind-closed-doors political maneuvering, any future government costs, no matter how high the taxes required or the debt incurred. He equates its passage to a massive civil rights law, a redistribution of wealth and social justice from the haves to the have-nots.

He believes the law will result in a high performing health system with better access, more affordable costs, improved outcome, and greater efficiency, in spite of growing evidence to the contrary in the first two years after its passage.

Historians will cherish this book. It is honest, not necessarily fair, but honest. It tells the inside story in detail – how President Obama stood up to close advisers, like Rahm Emanuel, who told him he should back off health care and focus more on the economy. It captures the complexity of the law – how it rolled ten pieces of legislation into one massive 2700 page bill, any piece of which may fail or be reversed.

No matter, it was the right thing to do. The health law is an enormously ambitious political act which runs the risk of being repealed or declared unconstitutional by the Supreme Court.

Physicians and the AMA

In the book physicians are given short shrift. Only 3 of its 339 pages are devoted to physician issues, of the AMA’s role in the scheme of things, and of the failure to reform the SGR (The Sustainable Growth Rate) formula, which is the basis for paying 570,000 physicians who bill Medicare. In McDonough’s words, “Physician-payment reform as part of comprehensive reform proved too heavy a challenge and financial lift.” By this he means Democrats could not fix SGR and still come under the $900 billion cost of the bill. As far as the AMA goes, it supported universal coverage and the individual mandate as well as many of the provisions of the law, at the heavy cost of loss of physician membership.

Tweet: Read Inside National Health Reform, an insider-book by a Democratic partisan of how the health reform bill came to be and what it portends for every American.