Book Review

Understanding Health Care Reform

Medicine's Dilemmas: Infinite Needs versus Finite Resources

N Engl J Med 1994; 331:1779December 29, 1994

Article

Understanding Health Care Reform
By Theodore R. Marmor. 288 pp. New Haven, Conn., Yale University Press, 1994. $35 (cloth); $14 (paper). ISBN: 0-300-05878-0 (cloth); 0-300-05879-9 (paper).

Medicine's Dilemmas: Infinite Needs versus Finite Resources
By William L. Kissick. 240 pp., illustrated. New Haven, Conn., Yale University Press, 1994. $25 (cloth); $12 (paper). ISBN: 0-300-05964-7 (cloth)

The father of one of us ran a hospital as a sideline to his full-time job as a radiologist (and single parent of four). Now whole legions daven over hospital management, academic departments analyze the analysts, and health policy books are reckoned up by dozens. Fortunately for the reader, most are obsolete before they are printed.

When President Bill Clinton embraced managed competition -- signaling that health care businesses would not just linger but flourish -- he unleashed an unprecedented torrent of mergers and acquisitions. Each month, thousands of physicians are forced into a bizarre variant of musical chairs: join up now, or be left out for good as patients are herded into restrictive managed-care systems. Merck, Lilly, and SmithKline paid $13 billion this year for firms that “manage” pharmaceutical care -- presaging the death of marketing through advertisements in journals and detailing. In its place will come drug choices made directly by drug-company subsidiaries. Blue Cross is going for-profit, buying hospitals, and setting up its own clinics. Mergers (brokered by business school, not medical school, deans) are consolidating hospitals in most cities into a few giant groups. In September 1993, Columbia Hospital Corporation swallowed Galen; in February, HCA; in September, HealthTrust (which had bought Epic in May). Now the company owns more than a third of Florida's hospital beds. Never has control of so vast an industry shifted so rapidly from a dispersed array of small producers -- doctors and local hospitals -- to a few huge corporations whose leveraged financial clout is their qualification for health care leadership.

This sudden shift has left health policy wonks in the dust. We are still writing about doctors, hospitals, and Washington policy debates. The real action is on Wall Street; the scenery, boardroom modern; the actors, investment bankers.

Marmor's book, an anthology of his essays (most coauthored) since 1986, is much better than most. A political scientist, he focuses on the molding of legislation and debate. He is weaker on the economic changes reshaping the health sector, which are addressed mainly in a superannuated essay contrasting for-profit and nonprofit health institutions.

A terrific chapter (coauthored by Jerry Mashaw) shows how managerial jargon (“integrated systems,” “outcomes management”) shrouds the real questions in reform, such as Who's in charge? and What are their goals? With journalist Tom Hamburger, Marmor examines how the media and foundations skew debate toward alternatives acceptable to their patrons. There is an effective argument for single-payer reform (with Carlos Cano), though Marmor's opening and closing essays urge compromises rendered moot by galloping corporate takeover. With Rudolf Klein, he uses the Canadian experience to explode the myth of inevitable conflicts among cost, quality, and access.

Kissick's book elevates this myth to the central tenet of health policy, dismissing mounds of evidence that other nations provide more, better, and cheaper care. Reducing administration, the profits of health maintenance organizations (HMOs), unneeded care, or seven-figure incomes need not compromise quality or access.

There is valuable historical material here on health policy in the United States (Kissick held key government posts from 1964 through 1969) and the United Kingdom (though he stops before Margaret Thatcher's policy changes). But his description of Canada is almost unrecognizable, including the curious claim that our health statistics are comparable (Canada's infant mortality is 26 percent lower and its life expectancy two years longer than ours). Most glaring is his naivete about the role of corporations in care. He wishes for a system centered around physician-run, nonprofit HMOs. Yet he advocates pro-market policies that ensure the ascendancy of for-profit providers whose superior access to capital (through stock offerings) is a decisive market advantage. Under the guise of competition we are galloping toward oligopoly. In Kissick's rosy world, the 145,000 physicians made surplus by lean staffing of HMOs will mean leisure time for community involvement, not two classes of doctors, one overworked and the other unemployed. He singles out for special praise U.S. Healthcare, a firm that spends only 70 percent of its premiums on care, whose chief executive officer took home $20.2 million last year (and held company stock worth $784 million more), and that gags its physicians with contract clauses prohibiting the disclosure of problems with quality.

Kissick wishes that doctors ran health care, but his policy prescriptions ensure that they will not. Do chefs run McDonald's?

Steffie Woolhandler, M.D., M.P.H.
David U. Himmelstein, M.D.
Cambridge Hospital, Cambridge, MA 02139