By the time of publication of the first edition of Governing Health: The Politics of Health Policy in 1996, the possibility of national health care reform – which had not long before seemed so bright – had severely dimmed. The Clinton Administration’s proposed comprehensive health plan—perhaps too comprehensive—had been found dead on arrival. Though Democrats controlled Congress, the plan failed in its first committee. And the defeat led to an election debacle for the party. Republicans took over both houses for the first time in 40 years—and they were not at all interested in health reform.
Governing Health chronicled that failure and more successful health policies in a book designed to provide a longitudinal view of policymaking that constitutes governing health. It’s an evolving process. In four subsequent volumes, the emergence of the Children’s Health Insurance Program, the Health Insurance Portability and Accountability Act, the massive cuts to Medicare and Medicaid that led to the only balanced US budget in the century, a new Part D drug coverage for Medicare, a new payment system for Medicare physicians tying payment to performance, and state policy innovations relating to Medicaid marijuana, the wide-spread use of managed care, efforts to control drug prices, the expanding role of allied health professionals, indefatigable state efforts to reduce drug prices, and diffusion of telemedicine and many more issues were highlighted and analyzed.
Health policy is nothing if not constantly changing. Even without a presidential or congressional election, it changes at least weekly, often daily. Thus to keep abreast of new developments, a book on its governance must be updated regularly. And it’s interesting stuff to follow. Just when you think you know how things work in the complex world of health policymaking and begin to feel you can predict what’s going to happen, you get a reality check.
When we started the 5th edition, President Trump had just been elected. His promise to repeal and replace Obamacare (the Affordable Care Act) was picked up by GOP candidates across the country and they were successful. So anyone betting that the ACA would not be repealed and signed by the new president would have demanded very long odds. But it didn’t happen. It came down to three votes in the Senate—three Republican votes—that defeated the repeal. And there was no real replacement in the offing.
Thus, ten years after its passage, the ACA seemed to have become part of the health policy landscape – along with Medicare, Medicaid, CHIP, other government programs, private employer insurance, and thriving insurance markets and accompanying lobbyists. The ACA is now popular as well. Case closed? Not exactly. President Trump’s Justice Department has supported the effort of a handful of Republican states arguing in court that the ACA is unconstitutional (this time because without the insurance mandate which was the linchpin of support in the 2012 Supreme Court case, the law no longer cuts constitutional muster). The case is working its way up to the Supreme Court, along with other judicial issues such as whether states can impose work requirements on applicants for Medicaid.
Another version of Governing Health, another health policy tsunami. Just business as usual in the health policy world.
Governing Health can’t be rewritten every week, of course, but we do try in each edition to make the illustrations that we offer from the years spanned by the writing of it to deliver insights that will help understand whatever new surprises the political and policy process reveal from time to time. The principles are drawn from political science and other social science research. They change at a much more sedate pace so these theories provide useful insights even as the facts change with the whims of presidents or the waxing and waning of party cohesion, majority control, and polarization.
We hope you enjoy reading the 5th edition as much as we enjoy following every nuance of change in health policy and choosing the most interesting of them to illustrate the theories of how health policy changes. Governing health mattered in 1996, and it matters today.
William G. Weissert is a professor of political science at Florida State University and a professor emeritus at the University of Michigan School of Public Health. Carol S. Weissert is the LeRoy Collins Eminent Scholar and a professor of political science at Florida State University. Together, they are the authors of Governing Health: The Politics of Health Policy, fifth edition.