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Jacob S. Hacker. The Road to Nowhere: The Genesis of President Clinton's Plan for Health Security. Princeton: Princeton University Press, 1997. 239 pp. $39.95 cloth.
On 22 September 1993, President Clinton stood before the United States Congress, and, despite a TelePrompTer stocked with the wrong words, gave one of the most soaring speeches of his presidency. Imploring the Congress to enact legislation that would ensure all Americans health care that can never be taken away, Clinton set off a national debate that would end less than one year later in his defeat, with his health care reform plan thoroughly discredited. Since then, numerous attempts have been made to explain why the president's health care reform proposal, the Health Security Act, did not become law. But until the publication of Jacob Hacker's Road to Nowhere, neither journalists nor academics have attempted a serious accounting of how exactly the President's bill made it onto the legislative agenda in the first place and why the Clinton administration adopted the kind of approach to health care reform that it did.
Hacker's cogent and concise book goes a long way toward addressing these fundamental questions. In many ways, the fate of health care reform in 1994 was decided neither in committee hearings nor in the political posturing of that year, but in the process that created the viable reform alternatives. The genesis of health care reform thus is not only a valuable case study for students of agenda-setting; it is also a window into why comprehensive health care reform was defeated in 1994 as it had been at least five times before in the twentieth century.
Some of the events Hacker delineates can be found in other works on the subject (Skocpol 1996; Johnson and Broder 1996), but as an intellectual history, his narrative is unrivaled. In brief, the events Hacker describes transpired as follows. In 1977, the economist Alain Enthoven (perhaps the central policy entrepreneur in Hacker's book) produced an innovative new approach to health care reform. The Consumer Choice Health Plan attempted to induce competition through a complicated mix of government regulation and individual choice. The centerpiece of Enthoven's plan required a significant expansion of organized delivery systems in place of the traditional fee-for-service market. In the late...