Abstract
Originally started as a guide to students for understanding and navigating the complicated, incremental process of health policy-making, this book by Beaufort B. Longest, Jr., of the University of Pittsburgh is now in its sixth edition. It reflects its author’s last name, as it extends to nearly 600 pages. In tracking the life cycle of health policy through conception, gestation, delivery, adaptation, and mutation, the individual chapters unfold a bit like a police procedural—minus the drama. The main effect of trying to be comprehensive and exhaustive actually produces a thinner layer of definition-dominated description lacking memorable analysis. In other words, it is much more of an introductory road map for health-policy tourists than a deeper work of penetrating insights.
The GPS stops include elaboration on the process of health policy-making (agenda setting, formulation, implementation, evaluation, and modification). Chapters on legislation development and policy implementation skim the surface, at best, but a new chapter on the role of courts is a more useful upgrade of past editions. The latter’s description of courts as “meaning givers” for enforcers and regulated parties, within the context of vague or ambiguous statutory language, is illuminating, but those insights should be extended to how sloppy or lazy legislative drafting shapes the rest of the policy-making processes described in the other chapters.
Too much of the book’s description of the health policy-making process begins and ends at a more simplified structural outline, without accounting for how it increasingly has operated differently in practice. For example, formal budgetary time lines and procedures often are bypassed. More politically contentious bills are crafted by top leadership and its staff, rather than through the committee process. The vagaries and conflicting objectives within final measures tend to reflect the complexities of assembling and maintaining workable majorities to support them.
Instead, the author briefly notes on several occasions that implementation of the Affordable Care Act (ACA) has been “difficult” but never really gets around to explaining why. An overview summary of the law in one of the book’s appendices fails to reflect how a number of its key provisions encountered substantial challenges in late 2013 and early 2014. The expanded use of interim final rules and subregulatory guidance to make several poorly drafted sections of statutory language more operational also receives too little attention.
If the main ten chapters (and 335 pages of text plus references) do not quite get the job done, there are another thirty appendices of supplemental material that mostly supply overviews of health programs and abbreviated examples of past legislative and regulatory policy-making. However, the process of dialing up scattered illustrations can seem almost random at times. A different approach might involve using a more limited set of major policy histories to track the cumulative process through which the book’s core elements of policy-making are developed.
A number of key factors behind the success or failure of proposed health policies in recent years still suffer from neglect. One finds only a brief, shallow mention of the role of the Congressional Budget Office, without any emphasis on its key gatekeeping role in determining whether proposed policy changes can meet budgetary and procedural tests, as well as metrics for cost and coverage effects. Despite a few token mentions of state-level policy-making, the book’s chapters remain overwhelmingly focused on the dynamics of federal government decisions. “Federalism” pops up only in the chapter on courts, in order to explain the underpinnings of the Supreme Court’s decision in 2012 to make the ACA’s expansion of Medicaid voluntary for state governments, in order to head off unduly coercive commandeering of their own role in health policy-making. However, the broader possibilities and limits of overlapping federal–state responsibilities in Medicaid and other health-policy issues remain unexamined.
Like many health-policy texts in this field, one finds the usual unchallenged premise at its core. Market failure necessitates many of the government interventions it observes. Despite some mentions of the political dynamics of concentrated interests and diffused costs, one searches in vain for more balanced recognition of broader examples of other “government” failures in health policy. Of course, the latter seem only to stimulate renewed demands to add new rounds of policy interventions on top of the accreted layers of preexisting ones.
Hence, there’s little doubt that there will be a market for a seventh edition of Health Policymaking in the United States. It may not really solve our various health-policy problems, but at least it insists that it is trying to help. Unfortunately, that mostly involves administering the same predictable sort of diagnoses and treatments that will leave us coping with, but not curing, the next stages of our chronic conditions. If you have limited expectations, this book will meet them.