Robert Saldin's When Bad Policy Makes Good Politics: Running the Numbers of Health Reform reveals how long-term care advocates leveraged the cost estimates from the Congressional Budget Office (CBO) to cajole and steer the Community Living Assistance Service and Support Act (CLASS) through the US Congress's arcane processes and rules. Supporters of CLASS embedded it in the 2010 Patient Protection and Affordable Care Act (ACA). Despite worthy goals, CLASS's policy flaws, particularly its voluntary enrollment and consequent vulnerability to adverse selection, would have rendered it unsustainable. At the same time, and counterintuitively, CLASS's design and financing provided approximately $72 billion in deficit reduction. Saldin argues this “accounting victory” was essential to Congress incorporating and retaining CLASS in the ACA.

Saldin's policy tracing is first-rate and is a core strength of When Bad Policy Makes Good Politics. CLASS was to collect premiums (i.e., revenues) for five years, and it deferred most benefits beyond the CBO's ten-year budget-scoring time frame. In the short term, the new law would deliver up-front reductions in the deficit. Eventually, however, CLASS benefits would deplete CLASS premium reserves, leaving its structural inadequacies and near-certain insolvency for later Congresses and administrations to remedy.

Recognizing its flaws, the Senate Health, Education, Labor, and Pensions Committee adopted an amendment by Senator Judd Gregg (R-NH) that required CLASS to achieve a seventy-five-year solvency. Saldin recognizes and skillfully presents the ironic politics of fixing CLASS via a Republican senator's amendment. Senator Gregg's amendment provided Democrats sufficient cover to keep CLASS while also delivering necessary deficit reductions in the ACA. Once the CBO score estimated that CLASS would “save” $72 billion over the first ten years of implementation (96), CLASS became a means for deficit reduction rather than an integral part of health care reform. The legislation was a vehicle for the ACA rather than the other way around. CBO Director Douglas Elmdorf reported to Senate Majority Leader Harry Reid separate budget projections and narrative analysis for CLASS. CBO distinguished CLASS from corresponding evaluations about the broader ACA (CBO 2009). Saldin forgoes explaining this distinction within the book, and readers may question whether ACA supporters and opponents alike understood that CLASS “piggybacked” on the more comprehensive and contentious ACA. The CBO's analytic distinction likely played a critical role in the Senate parliamentarian's ruling that sustained CLASS over senators' objections and precluded its reconsideration in the “sidecar” reconciliation bill that Democrats relied on to amend the Senate's health care reform.

Throughout When Bad Policy Makes Good Politics, Saldin refers to CLASS revenues in one form or another as budget savings (see esp. 96–99, 105–6). A more accurate description of CLASS's fiscal effects is as deficit reduction. By collecting premiums early and delaying benefits, CLASS would have created a stream of pooled and reserved revenues that would have decreased US budget deficits by $72 billion through 2020. This distinction goes beyond semantics. Although CLASS could have contributed to lower deficits, advocates did not promote this outcome, and CBO did not evaluate CLASS as a means of achieving reduced outlays beyond very modest Medicaid savings (CBO 2009).

Chapter 7 compares previous Democratic and Republican policy initiatives that relied on budget reconciliation to advance contentious legislation. The budget politics that shaped CLASS are comparable to those that shaped and eventually passed Medicare Part D. The Medicare Modernization Act of 2003 (MMA), championed by President George W. Bush, called for a new prescription drug addition to Medicare, which increased its budgetary ceiling by a proposed $400 billion over the first ten years. Like CLASS, Medicare Part D front-loaded revenues and delayed costs. Unlike CLASS, MMA had a narrower goal of prescription drug coverage. Congress structured both MMA and CLASS to withstand and be advanced within CBO's budget rules. This chapter is succinct yet superbly informative and provides a foundation for further budget politics research.

Saldin recognizes that Medicaid remains a primary revenue source for nursing homes and that the omission of long-term care benefits from Medicare has bedeviled health care politics for fifty years. The author deftly illustrates past efforts to improve seniors' financial security via Medicare, such as the Medicare Catastrophic Coverage Act. However, he leaves open whether CLASS may have provided a foundation for a fully comprehensive social insurance program for the elderly.

When Bad Policy Makes Good Politics is a direct and thoughtful contribution to our understanding of specific health politics during the tumult of the ACA's legislative development. Saldin's attentive and thorough contribution improves our understanding of how budget politics are ubiquitous and likely to produce counterintuitive and counterproductive public policy. When Bad Policy Makes Good Politics will be of interest to legislative, budget, and health politics scholars and provides many avenues for further research. Saldin's contribution adds much to broader ACA scholarship, such as Paul Starr's Remedy and Reaction: The Peculiar Struggle over Health Care Reform (2011) and Lawrence R. Jacobs and Theda Skocpol's Health Care Reform and American Politics: What Everyone Needs to Know (2010).

Glenn Beamer is associate professor in the School of Health and Medical Sciences at Seton Hall University. His work includes Creative Politics: Taxes and Public Goods in a Federal System (1999) and articles in the Policy Studies Journal, State Politics and Policy Quarterly, and Journal of Health Politics, Policy and Law.

Tyler M. Gibbons is a graduate student in the Master of Healthcare Administration (MHA) program at Seton Hall University. He received his BS in biology from Seton Hall and is the president of the MHA student advisory committee.


CBO (Congressional Budget Office)
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Manager's Amendment to the Patient Protection and Affordable Care Act
Washington, DC
Congressional Budget Office