Experiencing Politics: A Legislator's Stories of Government and Health Care (review)

John E. McDonough. Experiencing Politics: A Legislator's Stories of Government and Health Care. Berkeley: University of California Press, 2000. 354 pp. $50.00 cloth; $19.95 paper.

Experiencing Politics makes an important contribution to several different literatures in a crisp, engaging style. Although many excellent studies of the policy-making process in health care have appeared in recent years, few have cast such a wide net. John McDonough melds his firsthand experiences as a Massachusetts state legislator with a careful consideration of agenda building, representation, legislative behavior, and theories of policy change.

Each chapter begins with a theoretical framework that is then applied to a case or set of issues. Drawing upon the work of Hannah Pitkin, E. E. Schattschneider, and Deborah Stone, McDonough illustrates how policy makers frame, claim, and debate significant health-policy issues. The book offers the reader an insider's perspective on the policy-making process from the rigors of campaigning to backroom negotiations over legislation and leadership positions.

McDonough believes that "politics, at its core, is about relationships" and argues that "one should never forget that at the heart of the process rests the ability to make people believe a candidate, and in the process, believe more in themselves" (45). The importance of building and maintaining relationships is a central theme of the book. McDonough brings a diverse set of perspectives to bear on the subject, from Edmund Burke to contemporary principal-agent theories. He views representation as a "subset of a much broader, dynamic relationship" that can be modeled using agency theory. The chapter on relationships discusses various options for controlling agents' behavior, illustrating key points with examples drawn from Medicaid and managed care, and an intriguing discussion of campaign finance reform. McDonough also explores how legislators cultivate relationships with principals as a means of acquiring, and subsequently using, formal leadership positions. McDonough observes that "representation, while important, is secondary to the power and requirements of relationships at all levels. The bond between voter and elected official, while vitally important, is only one of many to be balanced by the public official" (168).

The growing popularity of rational choice models over the past two decades has led many political scientists to adopt, implicitly or explicitly, the assumption that self-interest dictates the behavior of legislators, interest groups, and the public. For McDonough, "Reality is more complicated. Oftentimes, political leaders make choices for political advantage and electoral concerns. And often they do not. Most politicians, from my close observation, are concerned with 'making good policy' and 'doing the right thing.' The fact that they also pay attention to the political consequences of their actions does not diminish that concern" (156).

The analysis of legislators' responses to the growing fiscal crisis in Massachusetts in the late 1980s is particularly sobering for students of state health policy. The projected size of the state's budget deficit in the late 1980s and early 1990s was a moving target, forcing lawmakers into increasingly difficult rounds of budget cuts, furloughs, layoffs, and program terminations. Elected officials struggled in a hostile environment to make sense of the magnitude of the problem. Legislators faced intense pressure from Wall Street investment firms to cut spending. At the same time, lawmakers were confronted by scores of visible victims and growing voter anger over tax increases and cutbacks in favored programs. Much of the debate over restoring Massachusetts's fiscal health revolved around controlling Medicaid expenditures. Most legislators ignored carefully constructed analyses that indicated that long-term care for the middle class, not acute care services for poor women and children, was the principal cause of Medicaid spending growth, and they instead targeted less visible, narrower constituencies for cutbacks.

McDonough also adds to our understanding of the circumstances under which health-policy change is possible at the state level. His discussion of the deregulation of Massachusetts's complex...