The Health Care Mess: How We Got into It and What It Will Take to Get Out
http://www.100md.com
《新英格兰医药杂志》
Sometimes you can judge a book by its cover. The authors are long-time advocates of a single-payer health care system and long-time skeptics about competition in health care. Both are Harvard professors — one a physician, the other a medical economist. Both served in two Democratic administrations: Richmond in the Johnson and Carter administrations, and Fein in the Truman and Kennedy administrations. Both have been active in various liberal causes. President Jimmy Carter wrote the book's foreword, and the back cover bears promotional blurbs from (among others) Senator Edward M. Kennedy and Daniel Schorr, a senior news analyst for National Public Radio.
The book delivers on the promise of the dust jacket, wearing both its heart and its policy prescriptions on its sleeve: universal coverage should be provided by a single-payer, mission-driven system. Health care policy should be turned over to physicians and academic medical centers. Taxes should be dramatically raised. Regulations should specify the optimal set of choices and options. For-profit enterprise should be bought out or marginalized, if not prohibited outright. The Federal Trade Commission should not interfere with health care. Regional and national operating and capital budgets should be prepared and enforced by new regional boards and a national, nonpartisan, quasi-governmental commission. The boards would be responsible for planning health care delivery systems in their respective regions. The Internal Revenue Service would collect the premiums.
Because the authors believe that the only way we will get a single-payer system is through an incremental approach, they propose to maintain temporarily employer-based health insurance and Medicare. As soon as it is feasible, everyone will be put into a single-payer system. Once that is done, then, as the authors explain, it is on to "examination of (and action in) housing, nutrition, economic status, employment, and the environment, among other areas. Universal health insurance and access and promotion of health . . . are more than matters of social policy and require a social revolution."
The authors imply their support for civic deliberation and bipartisan compromise, but their choice of four photographs to illustrate the book is telling: President Lyndon B. Johnson and President Harry S. Truman (at the signing of the Medicare bill in 1965), Harvard Medical School dean Robert H. Ebert (protesting the Vietnam War in 1969), Senator Kennedy (arguing in favor of National Health Insurance in 1974), and President William J. Clinton (announcing the completion of the initial sequencing of the human genome in 2000). It is clear who the authors think is leading the march of progress and where they should head.
The value of the book does not lie in its novelty. Those who already believe in a single-payer system will find themselves nodding in agreement. Those who are skeptical will find nothing to change their minds. The major themes of the book are also prefigured in the authors' 1995 article in the Journal of the American Medical Association, which bears a strikingly similar title ("The Health Care Mess: A Bit of History." JAMA 1995;273:69-71). The book is also focused disproportionately on issues that are important to medical education and teaching hospitals — which is not so surprising, considering that Richmond and Fein have spent most of their careers in prestigious academic medical centers.
Why, then, should one read this book? Over the course of their distinguished careers, the authors have participated in innumerable debates on matters of health care policy, large and small. They are veterans of fights over covering the uninsured, physician training, mental health, and substance abuse, and over funding for research, patient care, and medical education. They have extensive experience with the behavior of federal and state agencies, academic medical centers, insurers, and bureaucrats and bureaucracies, along with deep knowledge of the varying ways in which the United States has financed and delivered health care services.
This book distills these experiences into a sophisticated historical and institutional perspective on why our health care system looks the way it does. The authors ably show how the U.S. medical establishment devoted its attention to fending off the government, only to be blindsided by the market. They show how health care reform has always involved both technical and political issues. They write sensibly and dispassionately about our public health infrastructure, medical malpractice, and several other policy issues that we confront in our various capacities as providers, patients, taxpayers, and citizens. Their historical perspective provides ample support for economist Stuart Altman's aphorism that universal health care coverage that protects one's turf is everyone's first choice — but everyone's second choice is to do nothing.
To summarize, the book is worth reading for the authors' perspective on how we ended up where we are and on ways and means of getting somewhere else, even if one does not share their views on either the optimal destination or the itinerary for getting there.
David A. Hyman, M.D., J.D.
University of Illinois
Champaign, IL 61820
dhyman@law.uiuc.edu(By Julius B. Richmond and)
The book delivers on the promise of the dust jacket, wearing both its heart and its policy prescriptions on its sleeve: universal coverage should be provided by a single-payer, mission-driven system. Health care policy should be turned over to physicians and academic medical centers. Taxes should be dramatically raised. Regulations should specify the optimal set of choices and options. For-profit enterprise should be bought out or marginalized, if not prohibited outright. The Federal Trade Commission should not interfere with health care. Regional and national operating and capital budgets should be prepared and enforced by new regional boards and a national, nonpartisan, quasi-governmental commission. The boards would be responsible for planning health care delivery systems in their respective regions. The Internal Revenue Service would collect the premiums.
Because the authors believe that the only way we will get a single-payer system is through an incremental approach, they propose to maintain temporarily employer-based health insurance and Medicare. As soon as it is feasible, everyone will be put into a single-payer system. Once that is done, then, as the authors explain, it is on to "examination of (and action in) housing, nutrition, economic status, employment, and the environment, among other areas. Universal health insurance and access and promotion of health . . . are more than matters of social policy and require a social revolution."
The authors imply their support for civic deliberation and bipartisan compromise, but their choice of four photographs to illustrate the book is telling: President Lyndon B. Johnson and President Harry S. Truman (at the signing of the Medicare bill in 1965), Harvard Medical School dean Robert H. Ebert (protesting the Vietnam War in 1969), Senator Kennedy (arguing in favor of National Health Insurance in 1974), and President William J. Clinton (announcing the completion of the initial sequencing of the human genome in 2000). It is clear who the authors think is leading the march of progress and where they should head.
The value of the book does not lie in its novelty. Those who already believe in a single-payer system will find themselves nodding in agreement. Those who are skeptical will find nothing to change their minds. The major themes of the book are also prefigured in the authors' 1995 article in the Journal of the American Medical Association, which bears a strikingly similar title ("The Health Care Mess: A Bit of History." JAMA 1995;273:69-71). The book is also focused disproportionately on issues that are important to medical education and teaching hospitals — which is not so surprising, considering that Richmond and Fein have spent most of their careers in prestigious academic medical centers.
Why, then, should one read this book? Over the course of their distinguished careers, the authors have participated in innumerable debates on matters of health care policy, large and small. They are veterans of fights over covering the uninsured, physician training, mental health, and substance abuse, and over funding for research, patient care, and medical education. They have extensive experience with the behavior of federal and state agencies, academic medical centers, insurers, and bureaucrats and bureaucracies, along with deep knowledge of the varying ways in which the United States has financed and delivered health care services.
This book distills these experiences into a sophisticated historical and institutional perspective on why our health care system looks the way it does. The authors ably show how the U.S. medical establishment devoted its attention to fending off the government, only to be blindsided by the market. They show how health care reform has always involved both technical and political issues. They write sensibly and dispassionately about our public health infrastructure, medical malpractice, and several other policy issues that we confront in our various capacities as providers, patients, taxpayers, and citizens. Their historical perspective provides ample support for economist Stuart Altman's aphorism that universal health care coverage that protects one's turf is everyone's first choice — but everyone's second choice is to do nothing.
To summarize, the book is worth reading for the authors' perspective on how we ended up where we are and on ways and means of getting somewhere else, even if one does not share their views on either the optimal destination or the itinerary for getting there.
David A. Hyman, M.D., J.D.
University of Illinois
Champaign, IL 61820
dhyman@law.uiuc.edu(By Julius B. Richmond and)