Curing the Crisis: Options for America's Health Care.

Lane, Julia

The importance of health care reform is obvious to anyone living in the United States today: it was a major issue in the presidential election, and continues to have almost daily coverage in the nation's major newspapers. Furthermore, almost every American has an opinion on What Should Be Done. It is difficult, however, for people not intimately involved in the field to keep track of all the different reform proposals--or even to identify whether the proposals such as pay or play, national health insurance and managed competition are the same beast under different names. Reagan's book plays a useful role in providing background information in a non-technical survey of the key issues. This is no mean achievement in view of the complexity of the subject, so I may be cavilling when I mention several distressing flaws. The first is that although the general outline of the book is logical, the organization within each chapter is poor, and it is difficult to follow the author's train of thought. This confusion is compounded by the somewhat incongruous writing style (especially evident in Chapter One) used to convey different points of view and the occasional tendency to jumble many thoughts together. Furthermore, although the author does a yeoman's task describing the costs and benefits of the different reform proposals, he fails to provide any quantitative estimates. In other words, since the book is written by a political scientist rather than an economist, the general approach may be jarring to readers trained in economics. A further flaw which is not attributable to the author is the inevitable tendency of books to become outdated almost as soon as they come off the press--thus the failure to discuss any specifics of Clinton's health care options.

Part One of the book is entitled "A Snapshot of Health Care Delivery Today." Although the writing in the first chapter is leaden, it does provide a useful "straw man" summary of the views of different participants in the field, and contrasts nicely with Chapter Two's more factual description of the current "system." Chapter Two is unfortunately rather jumbled: the description of the system today precedes the historical description; the orienting questions; the subheadings and occasionally even the headings frequently do not reflect the content of the text; bald assertions are made without substantiating evidence or references and the language is often vague. For example, under the subheading "An Organizational Revolution in Health Care," we are told that the dominant mode of organization is the solo practice doctor and a free-standing hospital, but that new patterns are emerging. Although a good description of HMO's and PPO's follows, the level and trends and importance of each type of organization are not documented, and the reader is not directed to sources of more information. Had I not agreed to review this book, I would probably have stopped reading it at this point. Fortunately, the subsequent sections were an improvement.

Part Two partially redeems the very shaky beginning. Reagan's description in Chapter Three of the problems facing the health care industry is well done, with several illuminating anecdotes, buttressed by quantitative evidence. Chapter Four's elucidation of the causes of the problem is similarly clear. However, most economists would probably prefer an extension of Reagan's rather limited discussion of the role of information (or lack of it) on the part of the consumer.

Part Three, which discusses the options and includes a description of other health care systems in Germany, Canada and Great Britain, is really the best part of the book. The author does a good job of outlining the fundamental tensions inherent in rationing an emotionally unrationable commodity, and delineating the ways in which other countries have addressed these tensions. The two chapters on cutting costs are strong on description, but the description is illuminated by anecdotes, all of which are very entertaining but give no idea of the order of magnitude of the problem. Several statements are simply not sensible: although it is clear that a "much faster rate of growth in GNP" would be "the best thing the national government could use its policy tools to encourage" that health care expenditures might increase without adding to its share of national income, it is less clear that this is a useful suggestion. Similar vague assertions about changing the culture of medicine to "almost certainly save billions of dollars" are not useful without documentation.

Part Four provides a summary of an "optimal" plan, wherein Reagan recommends a Play or Pay system. Although he consistently fails to document the order of magnitude of the costs and benefits of such a system, he does identify the major strengths and weaknesses of the program. It is a shame that the book is not more current, so that the specifics of the Clinton proposal could have been more thoroughly discussed.

An economist is likely to come away from reading this book with mixed feelings. On the one hand, the book is a relatively easy read and there are some very useful pieces of information scattered throughout the text. Thus an undergraduate class could gainfully be asked to read through it for background material. On the other hand, when Reagan begins to elucidate his own views, he contributes little to the current debate given his irritating lack of substantiation. The cost/benefit ratio on reading the book is thus about unity. Julia Lane The American University