Health Affairs, 28, no. 5 (2009): 1545-1546 doi: 10.1377/hlthaff.28.5.1545 © 2009 by Project HOPE	New Online   Senate Health Reform Bill   Rewarding Providers   Public Option Policy Brief   Health Reform & Abortion   Delivery System Reform

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Book Reviews

BOOK REVIEWS

Wrestling With The Dragon: Presidential Power And Health Reform

Our founding fathers bequeathed us divided government. They did so for an understandable reason: having put "their lives, fortunes and sacred honor" at risk to separate from a British tyrant, they took pains in our Constitution to ensure that we would never have our own imperial leader. And yet, as David Blumenthal and James Morone argue in their book, The Heart of Power, to achieve health reform requires not only strong presidential leadership, but a strong presidency.

The Heart of Power is a labor of love and an explicit homage to Harvard’s legendary scholar of the presidency, Richard Neustadt. Blumenthal, an internist and the Obama administration’s health information technology czar, and Morone, chair of Political Science at Brown University, have brought us an epic study of the exercise of presidential power.

The Heart of Power tells how eleven modern presidents approached the issue of health reform. But more than dry history or political science, it is an intensely personal set of presidential stories that frame presidents’ actions against their and their families’ health care experiences. Precisely because health care is so intimately interwoven into the lives of all Americans, every citizen has a strong opinion about what he or she needs and is willing to change. As a result, changing the health system requires a copious expenditure of political capital. According to Blumenthal and Morone, accomplishing health reform requires not only tactical brilliance and managerial skill, but also the courage to expend political capital by the truckload.

The book pivots around Lyndon Johnson’s remarkable 1965 legislative onslaught that included the enactment of Medicare and Medicaid. The authors distill from the Johnson victory eight rules for successfully accomplishing health reform, to which they return at the end of their book. Ironically, Johnson’s victory made achieving universal coverage harder. Medicare and Medicaid added two core Democratic constituencies—the poor and the elderly—to coverage, joining veterans and unionized workers. After Medicare and Medicaid, what remained of the uninsured was a fragmented assemblage of relatively low-value targets: young adults, widows, the recently unemployed, the growing number of self-employed, and, as we entered the 1990s, newly arrived immigrants, both legal and illegal. The absence of high-value political targets made health reform a less attractive place for subsequent presidents to place their bets.

The Heart of Power also sheds valuable light on the tricky partnership between the presidency and Congress in accomplishing health reform. The modern presidency has been transformed into a "permanent campaign," striving, often unsuccessfully, to manage the political narrative almost hourly. Congress has changed as dramatically—from a somnolent, alcohol-soaked Men’s Club to a much more diverse, albeit bitterly polarized, body, dominated by a handful of media-savvy elected leaders. This book makes clear that to a great degree, the fate of health reform has turned on the capacity of the president to manage his relationship to Congress. It is not merely the president’s power to persuade as Neustadt taught, but the power to flatter, to co-opt, and to share credit that holds the key to success.

The authors are not ideologically neutral. Their belief that health care is a public good that should be managed publicly shines through. They view those presidents who tilted toward greater emphasis on markets, personal responsibility, or fiscal discipline as straying from the true path. The book’s comparatively narrow definition of health reform as enfranchisement—as extending benefits—certainly merits discussion.

One troubling argument of the book is the importance of "muzzling the economists" in achieving health reform. The rising influence of the federal Office of Management and Budget (OMB), the president’s Council of Economic Advisers, and the Congressional Budget Office (CBO) is viewed as a problem for health reform, which skillful presidents must artfully deflect. The "economists" in The Heart of Power seem like a cloud of locusts (you can almost hear them buzzing and clicking).

As the current OMB director, Peter Orszag, who has become a scholar of the health system and is no locust, understands well, as health care spending nears 18 percent of gross domestic product (GDP), health policy has become economic policy. Merely shunting the economists aside without asking the "value-for-money" question about health reform is not responsible public policy.

The progress that the authors laud in covering Americans has come at a steep price: a forty-year stretch of hyperinflation in U.S. health costs that has not only robbed workers of wage gains and damaged American business competitiveness in global markets, but also limited governmental resources to address critical unmet needs. Medicare alone represents, by some estimates, a nearly $50 trillion claim on the nation’s future wealth.

Thoughtful economic stewardship is the foremost domestic policy challenge for any president. The authors slight Presidents Reagan, Bush I, and Clinton for their health care leadership, yet their victories in economic and fiscal policy played a major role in more than two decades of U.S. prosperity—hardly an insignificant legacy. Reagan and Bush I, who presided over the most important reforms in Medicare payment in the program’s history, and Clinton, who balanced the federal budget largely by containing health spending, deserve far more credit than they are given here.

That the United States has managed to exceed any other major country in per capita public spending on health and still leaves forty-six million people without coverage should illustrate the moral price of ignoring the social value of health spending. Coverage does not guarantee access, and access does not guarantee health. Achieving universal coverage should be viewed as the health policy equivalent of the Voting Rights Act: an important step toward a healthier society, but certainly not "mission accomplished."

Nonetheless, this book is an engrossing and brilliantly written analysis of political institutions and national leaders, whose humanity—strengths and flaws—illuminates the narrative. Health reform is as hard as it gets—a demanding test of presidential leadership. I didn’t want this book to end, and indeed, it has not. The Obama administration is writing a new chapter right now and appears to have learned many of the vital lessons of prior presidencies as it dances with Congress to frame health reform. The Heart of Power is a masterpiece and a valuable primer for future presidents as they wrestle with the dragon of health reform.

Jeff Goldsmith

Editor's Notes

 
Jeff Goldsmith (tcoyote{at}msn.com) is president of Health Futures Inc. in Charlottesville, Virginia, and an associate professor of public health sciences at the University of Virginia.

Jeff Goldsmith is not an economist, but he is a long-time colleague of David Blumenthal’s and a coauthor with him of a 2003 Health Affairs paper on federal health information policy.

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