Crossing the Health Care Chasm: Finding the Path to Bipartisan Collaboration in National Health Care Policy

Book Title: Crossing the Health Care Chasm: Finding the Path to Bipartisan Collaboration in National Health Care Policy  

Author: Donald A. Barr

Publication Details: Baltimore, MD, John's Hopkins Press, 2021, 270 pp., $30, hardcover and e-book

Crossing the Health Care Chasm: Finding the Path to Bipartisan Collaboration in National Health Care Policy reviews the history of health policy legislation in the United States. It begins with the attempt by President Truman after World War II to achieve universal coverage and describes the compromises that created Medicare and Medicaid. Donald Barr, MD, PhD, attributes the failure of the Clinton administration to achieve universal coverage to the inability of the Clintons to work collaboratively across the aisle and describes the bipartisan work that led to the creation of the Children’s Health Insurance Program and Medicare Part D. A chapter details the process of negation between stakeholders that allowed passage of the Affordable Care Act (ACA) and the (in his view, unfortunate) reconciliation through which the final amendments necessary for the act’s passage were made. The next chapters cover the latter part of the Obama administration and the Trump years and discuss Republican attempts to “repeal and replace” the ACA without ever saying with what they would replace it, only that it would be better. He discusses several of the court challenges to the ACA and the unintended consequences of the judgements.

Barr argues that leaders of both parties, and most of the public, agree on several things that need to be done to make health care more affordable. Limiting the cost of medications is clearly necessary both for good care and to reduce unnecessary hospitalizations. “Silver loading” (setting artificially high prices for silver-level plans—a tactic occasioned by Congress’s failure to authorize cost compensation to the health insurers) and the “family glitch” (due to which some low-income families are excluded from both Medicaid and exchange subsidies) are issues that most everyone agrees need to be fixed. Barr's descriptions of these issues are detailed at perhaps too great length. 

One bipartisan collaborative left out of the book successfully eliminated the Sustainable Growth Rate adjustment, an annual potential calamity for primary care physicians, using the strategy of attaching the provision to must-pass legislation. This is a tactic that party leaders, using the leverage of the Senate Finance and House Budget Committees (whose members they have carefully selected), have used to stifle the objections of the more extreme members in their chambers.  

Barr uses the analogy of a rope bridge built collaboratively by villagers on both sides of a chasm to describe how, working on one issue at a time, Democrats and Republicans can build trust and solve some of the issues on which there is broad public and stakeholder agreement. Although this is probably the most likely way for us to move forward, he may be overly optimistic. In this period, unfortunately, some members of each tribe seem to be actively trying to cast the bridge builders into the chasm, and some villagers on each side fear (with some justification) that the other tribe would only use the bridge to cross over and burn their village to the ground. 

This book could be used as part of a health policy class or as part of the required reading in an advocacy curriculum. The author communicates clearly how Congress works and what it takes to get a policy idea across the finish line. Readers interested in the history of US health policy might prefer starting at an earlier point in time (such as the period before World War I when a Prussian-style national health insurance was contemplated) and passing over some of the details of the current issues. Readers involved in current advocacy might want a resource that is briefer and more focused on the current issues and forces in play in the present time.