Book Review

A Second Opinion: Rescuing America's Health Care

N Engl J Med 2007; 356:2756June 28, 2007

Article

A Second Opinion: Rescuing America's Health Care
(A Century Foundation Book.) By Arnold S. Relman. 205 pp. New York, PublicAffairs, 2007. $24. ISBN: 978-1-58648-481-1

Usually, second opinions are requested by patients to gain a better understanding of their disease and how to manage it. In the case of Arnold Relman's book, the patient is the American public and the disease is the U.S. health care system. The public did not request this second opinion, but from it they would certainly gain a better understanding of the pathology of the health system and why previous opinions have fallen far short of producing a cure.

The book has three interwoven components: a factual review of historical currents in U.S. health care, a critique of current ideas on reform, and a detailed proposal for the future. The historical analysis is unique in its emphasis on the commercialization of health care and the attempt by for-profit companies and sympathetic economists to transform health care from a human service into a market commodity. For Relman, the physician is a blend of professional and businessperson, but the “commercial tsunami” of the 1970s and 1980s has strengthened the business side of medicine to the detriment of professional and ethical concerns.

Relman's proposal for reform stems from his analysis that the root problem in U.S. health care is the primacy of profits over patients. In both the financial (insurance) and delivery (hospitals, physician organizations, and other provider institutions) sectors of the health system, Relman would eliminate for-profit companies. Whereas most health care reform plans limit themselves to the financing of care through some type of universal insurance, Relman advocates for major changes in health care delivery as well.

In keeping with the goal of decommercialization, Relman would finance the health care system with one governmental or quasi-governmental insurer, which would in turn be financed by a tax earmarked for health care. But he goes far beyond single-payer financing; his call for reform of the delivery of care would have physicians providing care through organized, not-for-profit, prepaid group practices. It is striking that about 50% of physicians currently practice in small offices, enterprises that often lack the resources — such as capital, managers with time to plan improvements, and nonphysician caregivers — to organize acute, chronic, and preventive care that is of consistently high quality. In Relman's plan, the number of patients in the primary care panel would be limited to 1500 (the U.S. average is 2300 patients), and half of physicians would practice primary care medicine, a proportion typical of most developed nations but not the United States.

Relman's proposal has the potential to solve the health care problem that he finds most vexing — the ever-rising cost of care. As costs go up, access goes down — thus, costs must be confronted. Because high costs can be associated with commercialization and a multi-insurer financing system, the dual remedies of a public or quasi-public insurance mechanism, combined with not-for-profit physician groups, are sensible.

A Second Opinion does not fall into the trap of most reform-minded health care policy writing — first assessing what is politically feasible and then tailoring solutions to what is possible rather than what is needed. In contrast, Relman describes “The Reform We Need” (chapter 5) and then asks “Can We Get There?” (chapter 6). It is difficult to deny that much of the health policy world features a debate between commercial interests, who will make things worse, and reformers, who offer half-solutions on how to make things better. This book offers fundamental change and concludes with a plea to the nation's physicians to lead the way.

Thomas Bodenheimer, M.D.
University of California, San Francisco, San Francisco, CA 94110
tbodenheimer@fcm.ucsf.edu