Book Review Health AffairsVol. 28, No. 2: Stimulating Health IT Investigating Our Fixation With Flawed Market SolutionsDavid A. RochefortPUBLISHED:March/April 2009Free Accesshttps://doi.org/10.1377/hlthaff.28.2.588AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSMarketsGovernment programs and policiesHealth maintenance organizationsPoliticsHealth insurance exchangesInsurance market regulation On 23 September 2008, syndicated columnist Martin Schram marveled in the Seattle Post-Intelligencer, “A new chapter of the presidential legacy of George W. Bush has now become clear: He, of all people, will inevitably go down as the president who brought socialism to the citadel of capitalism—Wall Street.” Schram’s was just one of many such comments—in the print media, on radio and television talk shows, in the blogosphere, and, one imagines, in the hallways of Congress—prompted by the role of the Republican leadership in formulating generous bailout packages for major investment houses, lending institutions, and auto manufacturers, all proud standard bearers of U.S. capitalism. To many, this public interventionism, coupled with support for expanded regulatory regimes, comes as a stunning development in light of familiar right-wing ideology. Readers of this book, however, will find no unexpected contradiction. Rather, as Lawrence Brown and Lawrence Jacobs explain, the history of recent decades in this country is replete with episodes in which the “hot pursuit of market alternatives to government” produced disappointment on a massive scale only to give rise to pleas from the most ardent free-enterprisers and privatizers for government to charge in and safeguard their interests. So it is that The Private Abuse of the Public Interest, although completed before the current economic malaise, supplies a key text for our times. The authors, two political scientists who have made outstanding contributions to the study of health policy and politics, provide a penetrating discussion of the tendency toward “market idealization” in U.S. public policy while tracking the systematic dysfunctions that result when government is demonized and sidelined. Their book is a lean 131 pages of tautly written text that deftly covers a few critical topics. Early chapters explain the rise and consolidation of “market utopianism” as a public philosophy since the 1960s. Adherents of this perspective achieved remarkable success in defining government as “the problem” in American society, pushing their arguments well beyond what even classical political economists like Adam Smith saw as the virtue of unregulated markets. The simplicity of this dogma has proved alluring indeed, gaining support not only from political conservatives but also, to some extent, from moderates like Bill Clinton and other New Democrats. Brown and Jacobs go on to detail the influence of market-oriented reforms in health care, education, and transportation. The common developmental pattern inside all three policy domains has been a heady enthusiasm for market-driven solutions followed by disenchantment once “grand theory” met “institutional reality” (p. 67). This latter collision, in turn, fueled renewed government involvement to protect consumers, as well as industry interests, from the ravages of unregulated market forces. As Brown and Jacobs state, “The last three and a half decades offer a political tale of government unceremoniously ushered out the front door of the nation’s collective abode only to be quietly readmitted via the back door” (p. 95). After an enlightening chapter documenting the growth of government under both Republicans and Democrats despite the ascendance of anti-big-government rhetoric, the authors concisely present their own case for the embrace of “pragmatic” public policies that unapologetically turn to government to constrain pro-market extremes.Interwoven discussion of multiple policy areas in this book is a useful device for identifying similarities that “transcend idiosyncratic details” (p. 38). Yet specialists may regret that their respective interests do not receive in-depth treatment in case studies of their own. Certainly, as these authors acknowledge, each topic presents interesting distinctions regarding interest-group formation, the design of legislation, and regulatory behavior. In regard to health care, Brown and Jacobs relate how health maintenance organizations (HMOs) emerged under President Richard Nixon in the early 1970s as a mainstream solution for health policy ills, particularly rising costs, because of their emphasis on consumer choice and expansion of the insurance marketplace: “Promoting HMOs entailed no comprehensive reforms, no public utility regulation, and no battles with beneficiaries in Medicaid and Medicare” (p. 52). Because of the lack of public supervision, however, it was inevitable that when the managed care movement surged in the 1980s and 1990s, cost-cutting abuses would arise on the part of some plans that threatened enrollees and providers alike. The response was a widespread political backlash leading to extensive new regulation on the state and federal levels. The authors do not delve into today’s conservative nostrum of “consumer-driven care,” although it fits nicely within their paradigm of market-based reforms gone awry. Even as insurers and employers have collaborated on a variety of measures to “sensitize” patients to the expensiveness of health care, health care spending has continued to rise, employer-based coverage has declined, and eroding benefits have aggravated the problem of underinsurance. It is something of a conundrum how conservative politicians and their allies call for marketplace competition in principle, while rushing in for special favors from government when those arrangements prove detrimental in practice. Is this “Jekyll and Hyde performance” merely symptomatic of a rude awakening from market romanticization? Or does it reflect a more “calculated logic” of conservatives “brandish[ing] their philosophical bona fides while seeking benefits for their prized exceptions” (p. 121)? Brown and Jacobs do not impose a single answer to this question on their readers, although those familiar with political-language expert Murray Edelman may find his work relevant here. Edelman wrote brilliantly about “construction of the political spectacle,” a process in which well-organized groups and political elites disseminate symbolic messages that rationalize, and conceal, their position of advantage vis-à-vis a poorly informed public. 1 Whatever the correct analysis may be, the authors of this valuable book are definitive on one issue: government by “philosophical exceptionalism” is likely to produce neither coherent public policy nor an inspiring vision of politics to lead us confidently into the future. David Rochefort ( [email protected] ) is Arts and Sciences Distinguished Professor of Political Science and Public Administration at Northeastern University in Boston, Massachusetts. NOTE1 M. Edelman , Constructing the Political Spectacle (Chicago: University of Chicago Press, 1988 ). Google Scholar Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 1 History Published online 1 March 2009 InformationCopyright 2009 by Project HOPE - The People-to-People Health Foundation, Inc.PDF downloadCited ByMission Not Yet Accomplished? Massachusetts Contemplates Major Moves On Cost ContainmentMartha Bebinger2 August 2017 | Health Affairs, Vol. 28, No. 5