Book Review

Health Care Politics

Medical Gridlock and Health Reform

N Engl J Med 1994; 331:1462-1463November 24, 1994

Article

Medical Gridlock and Health Reform
By Eli Ginzberg. 204 pp. Boulder, Colo., Westview Press, 1994. $55. ISBN: 0-8133-2040-2

As the national debate on health care reform continues, it is helpful to be reminded that this is not a new issue and that there are applicable lessons to be learned from past efforts. Professor Eli Ginzberg has observed and participated in those efforts for more than half a century, and his recent book, Medical Gridlock and Health Reform, presents many insights useful today. Most of the chapters have been published separately in health care journals over the past three or four years. They are gathered here and updated, with some current material added that deals with President Clinton's proposal for health care reform.

Beginning with his experience as chief logistical advisor to the surgeon general of the army during World War II, Ginzberg has focused on health care as a system and has repeatedly pointed out the need to view our national health care as a whole and to make improvements accordingly. A vigorously independent thinker, Ginzberg charts a course that will be fully acceptable neither to the right nor to the left in the current political debate.

Repeatedly, Ginzberg makes his point about focusing on the entire health system by calling for global budgeting -- what he calls “putting in place an effective mechanism that will limit the total amount of money that the three principal payers (the federal government, employers and state governments) will contribute.” He couples this with a call for universal health insurance and for controls on the supply of physicians, hospital capacity, and the diffusion of technological innovations. Not surprisingly, given these recommendations, he is opposed to the notion of managed competition as a strategy for reforming the U.S. health care system. He asserts that the critical lesson of the past several decades is that the competitive market is not an appropriate model for health care.

Ginzberg states that a health care system must protect citizens against large out-of-pocket expenditures and provide them with ready access to essential services. He says that unassisted by regulation, the competitive market cannot meet either test, much less both, at an affordable cost.

Given the large scale of the changes he thinks are needed, Ginzberg is surprisingly realistic about their chances of enactment. He cogently explains our inherently slow-to-change governmental system: the American predilection for taking small steps in public policy, our pluralistic health care system, the fact that the public wants more (not fewer) health care services, and the reality that employers, a force to be reckoned with, are not convinced that they should support mandatory health coverage for all regular employees. He highlights the fact that the dominant interest groups, including the major providers, have not agreed on how to change the existing system to accomplish widely desired reforms.

Despite the obstacles to large-scale change, Ginzberg is persuaded that the system cannot continue long on its present course. He says that the annual national health expenditure of nearly $1 trillion will prompt action soon. He predicts that growing concern about escalating costs will derail the status quo and that this factor, coupled with spreading anxiety in the general public about the curtailment of health benefits, will lead to “the pot boiling over” before or after the 1996 election.

Ginzberg explains clearly that with a global national health budget and the resulting moderation in the flow of new dollars into the health care system, the growth rate of physicians' earnings will slow. He goes on to describe the central importance of “significant alterations in how physicians currently practice, how they are paid, and how much they are permitted to earn” in constraining overall health care costs.

The book concludes with an assessment of President Clinton's proposal for health care reform in which Ginzberg praises Clinton's endorsement of global budgeting and universal health insurance coverage. “It is hard to see how Congress can fail to go along with the president's recommendation.” Here Ginzberg errs, as has already been demonstrated this year. If Congress does pass major health care reform in the next session, and that is by no means certain, it will probably be quite different from the Clinton proposal.

The explanation for Ginzberg's mistaken assertion lies elsewhere in this very readable book. He states that the critical step in implementing global budgeting is to engage broad public support for action now. The debate of the past year and a half has yielded much heat and shed little light on the subject. It surely has not produced “broad public support” for global budgeting, and perhaps not even for action on health care reform at all.

William L. Roper, M.D.
Prudential Center for Health Care Research, Atlanta, GA 30339