The Political Life of Medicare: American Politics and Political Economy (review)

This book is a valuable contribution to the contemporary history of health policy. Jonathan Oberlander grounds his narrative in primary sources, and his analysis in a trenchant critique of relevant theory in political science.

"From 1966 to 1994," Oberlander writes, "Medicare was governed by the politics of consensus" which "fractured in 1995" (pp. 6-7). During the years of consensus, federal policymakers in both parties, led by members of Congress, managed tensions "embedded in the program's structure at its inception" (p. 8). They did this by asserting governmental authority in ways that usually were independent both from the interest groups representing physicians, hospitals, and providers of long-term care, and from public opinion as revealed in surveys. However, the consensus broke down as a result of the bitter conflict about the scope of the federal government that has dominated domestic politics since the elections of 1994. The politics of Medicare, including the run-up to the enactment of extensive and expensive Medicare legislation late in 2003 (after publication of this book), has been a "battle of ideas about the role of markets and government in public policy" (p. 196).

Oberlander concludes that the current debate "is, in many respects, the same debate" that occurred before the enactment of Medicare (p. 196). Much of the rhetoric is the same, but the politics is very different. The three decades of consensus politics that Oberlander describes so incisively was the result of the dominance in Congress of a bipartisan centrist majority. The members who comprised this majority assumed that as a result of events in the 1930s and 1940s government was the guarantor of Americans' security against poverty, illness, and foreign enemies. However, the center in American politics moved to the right in the three decades after 1964. After the election of 1994, a new Republican majority in the House could credibly declare ideological war on six decades of American policy that had made government the guarantor of security against poverty and illness. From the late 1950s until 1994 a majority in Congress usually resolved debates between government and markets in favor of government. By 2003, proponents of market solutions were ascendant.

Oberlander's claim that the Medicare consensus "was an elite rather than public phenomenon" (p. 7) is overstated. Although members of Congress discuss many issues to which their constituents are inattentive, they rarely make policy that is not acceptable or at least plausible to the voters who send them to office and can send them home. Congress quickly repealed the Medicare Catastrophic Coverage Act of 1988 when it proved unpopular, as Oberlander describes. Fortunately, he retreats from his claim of elitism later in the book. He writes that public opinion often "reinforces" the "preferences" of policymakers "rather than serving as their source" (p. 142); it follows that public opinion also constrains those preferences.

Moreover, policymakers understand better than Oberlander does that many voters have opinions they prefer not to talk about. For example, many Medicare beneficiaries make themselves eligible for Medicaid coverage for long-term care in order to protect their inheritable assets. Oberlander omits Medicare beneficiaries and their prospective heirs from his list of constituents of Medicaid (p. 141); the persons these constituents send to Congress are, however, very much aware of the preferences of these voters and of the social and moral ambiguity that makes them inarticulate.

These strictures are merely minor disagreements about a major contribution to the contemporary history of health policy. Oberlander is one of a growing number of historians (others include David Moss, James Wooten, and Julian Zelizer) who are demonstrating that what policymakers actually do to shape the substance of policy challenges years of theorizing by academics about the weakness of the American state, the determinative power of interest groups, and the influence of public opinion on policy.