Despite my lifelong involvement in and study of American health- care policy, I learned a great deal from this book. I was not fully appreciative, for example, of the depth and passion of Truman's commitment to a social insurance model of national health insurance, nor was I aware of the level of detailed involvement by Lyndon Johnson in the birth of Medicare, the federal insurance program for the elderly. It was part of a conscious strategy on Lyndon Baines Johnson's (LBJ) part to give Representative Wilbur Mills most of the credit for passing that landmark legislation in 1965. Flattery, it turns out, is an important policy tool. There are many other examples. The final chapter called "Eight Rules For The Heart of Power' is thoughtful and thought-provoking. I won't spoil the ending by listing them here.
Most important, the authors drew on their own experiences as political scientist and physician, as scholars, researchers, and participants in our chaotic and bewildering policy process. Together, they have created a fascinating story of health policy development over a period of more than 75 years. This book is well worth reading by anyone interested in the role of US presidents and the presidency in the development of American health policy.
Still, after reading the book, I was left with the feeling that an important set of issues legitimately beyond the scope of The Heart of Power were left unaddressed. As this book makes clear, in the health field strong presidential leadership is critical to enacting major legislation. Yet, even the most skillful, determined, and powerful president is limited by the political environment of the day. Contrary to the rhetoric, politicians are usually followers, not leaders of popular sentiment. There is only so much any leader can do before he runs up against the barriers to change inherent in the political environment of the day.
What are the barriers to reform of the American health-care system? Why has it been so difficult for American politicians to create a statutory right to health care for Americans a right that every other affluent democracy created years ago?
First and most basic, the concept of health care as a right remains a polarizing concept in the United States. As Lewis Carroll once said, "If you don't know where you're going, any road will get you there'. The wisdom of that observation is clear to anybody watching Congress struggle with the issues raised by the most recent health- care reform effort.
Second, Americans are inherently suspicious of central authority secular or religious. Thomas Paine's concept of government as "a necessary evil' is alive and well. Establishing a right to health care requires a stiff dose of that necessary evil. Our political institutions are designed to decentralize power.
Third, the idea that America is exceptional and not governed by the rules most other countries follow is still widely held in the United States, however misguided. That makes it difficult for Americans to learn from experience in other nations, or even to be told that there are lessons to be learned from others.
Fourth, only in America has corporatism engulfed so much of medical care and come so close to dominating the doctorpatient relationship. Publicly traded, profit-driven entities now dominate the financing and delivery of medical care in the United States to an extent seen nowhere else in the world. This may be the single most distinguishing characteristic of the modern American health-care system, and the one that has had the most profound impact on it since the early 1980s. The theology of the market and the strongly held belief that the problems of American health care can be solved if only the market could be perfected have most effectively obstructed the development of a rational, efficient, and humane national health- care policy.
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