Book Review

Competing Solutions: American health care proposals and international experience

N Engl J Med 1996; 334:61-62January 4, 1996

Article

Competing Solutions: American health care proposals and international experience
By Joseph White. 392 pp. Washington, D.C., Brookings Institution, 1995. $38.95. ISBN: 0-8157-9364-2

It is now generally agreed, though Americans do not usually celebrate the point, that we cannot have it all: universal access to high-quality health care at moderate and stable costs. Joseph White, a research associate at the Brookings Institution (which also published his book) disagrees. White claims that we can resolve our health care problems by transforming the present situation, in part by eclectically adopting the best policies, or “key measures,” of six nations (Canada, the United Kingdom, Australia, Germany, France, and Japan), “choosing aspects of the framework that works in international experience.” He seems unaware of the informal fallacy of composition to which he has succumbed: that one cannot necessarily infer that the superior athletes selected from many teams (read, nations) to perform as an all-star team (read, United States) will play together as well as any of the other non–all-star teams. White also reviews various competing solutions to health care problems, focusing on managed competition; its theoretical framework, structure, and flaws; and the mass of federal regulations following in its wake.

If the solution White proposes is to be of real value, of course, sick, suffering, and dying Americans must have access to health professionals — i.e., treatment, not simply the promise of access and treatment. However, White's appreciation (experience?) of the actual clinical context — the “laying on of hands” by physicians and nurses who initiate the initial payment documents — does not emerge in the 308 pages of text and the 70 pages of helpful notes. This is important, because the principal failing of this book, which has many virtues, is the author's limited understanding of the meaning for patients and physicians of quality of care (in spite of the gloss he gives the notion in chapter 6), which is a notion critical to his thesis that we can have it all: affordable, accessible, and high-quality health care.

In defending his thesis, White divides his analysis into two parts. The first is a detailed review of the present U.S. health care system (comparing it with those in six other nations). He concludes that we can benefit if we are willing to learn from the key measures of these nations and then modify our system by adopting what is best in them, or at least avoiding what is worst in them. The second part is a review of various competing solutions, focusing on a variety of aspects of managed competition.

More important, White offers no critical political philosophical analysis for his position, except the one he presumes: in a market-driven democracy “health care is simply a consumption good.” For example, at one point he concludes somewhat cryptically that “The Clinton proposal had most of what would be needed to control costs in a fee-for-service sector.” Perhaps this political philosophy is all he need assume for readers who share his ideology. But notwithstanding this unwritten “argument,” White's eclecticism still has its intrinsic limits.

In the end, the sound research on which this book is based makes it important reading, despite the fact that the task of following the arguments pertinent to all the interrelations among the economic factors and other details will in all likelihood compel the reader to conclude that it has been a difficult book to understand fully. Having said this, I think that Competing Solutions surely deserves to be read again.

Stuart F. Spicker, Ph.D.
Baylor College of Medicine, Houston, TX 77030-3498