Critical Condition: How Health Care in America Became Big Business — and Bad Medicine
http://www.100md.com
《新英格兰医药杂志》
Love thy neighbor: an American paradox? The United States has one of the highest levels of church attendance in the world, but when it comes to health care, it seems that churchgoers find it difficult to love their neighbors in the way that secular Europeans take for granted.
Critical Condition, a fine polemic, describes how health care in the United States is financially rewarding to insurers and providers but delivers poor-quality health care to many of its citizens. Although U.S. health care has been described as the "best system in the world" (and it is in parts), it is also a failure because of its inability to deliver good-quality care to the disadvantaged. However, this paradox is also the triumph of the system, since its component parts do what they are designed to do. Medicaid provides variable support for some of the poor. Medicare offers a finite package of care for the elderly, with patients in the eastern United States receiving 60 percent more care than those in the West. Veterans are cared for in a mini–National Health Service, which appears to have had some success in shifting cases from the hospital to primary care settings. The majority of U.S. workers are offered little choice in insurance plans by their employers, who, confronted by an escalation in costs, increasingly have recourse to higher levels of deductibles and copayments and are pruning benefit packages. Then there are the 43 million Americans with no health insurance. Over the life cycle, the American lottery can move people across these systems with significant consequences for their material well-being and health.
In each of these health care systems, Americans face price discrimination and bankruptcy if they are unlucky in their genes and life events. In their book, Barlett and Steele describe these problems in graphic detail. They explain how, instead of cross-subsidizing the poor with revenues from people who are more affluent, providers charge them higher prices for the same services as those received by the more fortunate. This price discrimination is supported by vigorous pursuit of people who fail to pay their health care debts.
American private-sector bureaucrats, like their public-sector counterparts in Europe, increasingly have recourse to "cookbook medicine," in which practice guidelines and protocols (all too often evidence-free) are imposed on practitioners. Given that medical practice exhibits established and significant variations and well-chronicled medical errors, together with a remarkable reluctance to measure success in improving the quality of life of patients, it is unsurprising that bureaucrats seek to establish quality standards in the health care industry. What is surprising is that their efforts in the United States and elsewhere remain feeble and are rarely "confused" by evidence of cost-effectiveness. But there again, this is no accident but, rather, the deliberate product of the incentive structures inherent in the U.S. health care system. These incentives protect the insurers and providers from contestability, muting price competition and ensuring that competition in quality is superficial and rarely informed by patient-outcome data.
Barlett and Steele offer a nicely documented and well-written insight into all that is bad with the U.S. health care system. For skeptical Europeans on the receiving end of evidence-free health care reforms often inspired by unevaluated policies from the United States, this book is a welcome antidote. There are no simple solutions to complex problems inherent in health care systems worldwide, and the authors' advocacy of national insurance as the solution to the problems of equity and access that they document is unconvincing. First, insurers and providers thrive at the current health care feast and are unlikely to support reforms that redistribute their jobs and incomes. Second, tax-financed national insurance does not address the problems of inefficiency in the supply of health care as demonstrated by Europe. National insurance enables societies to love their neighbors, but as Adam Smith, the 18th-century Scottish economist, noted, capitalists always conspire to exploit the consumer, and nowhere is this more evident than in the health care sector.
Will Barlett and Steele precipitate altruistic reform, unlike their many predecessors who have described the failings of U.S. health care? The recent presidential election makes this unlikely. Americans appear to prefer to practice their religion in isolation from their social policies.
Alan K. Maynard
University of York
York YO10 5DD, United Kingdom
akm3@york.ac.uk(Donald L. Barlett and Jam)
Critical Condition, a fine polemic, describes how health care in the United States is financially rewarding to insurers and providers but delivers poor-quality health care to many of its citizens. Although U.S. health care has been described as the "best system in the world" (and it is in parts), it is also a failure because of its inability to deliver good-quality care to the disadvantaged. However, this paradox is also the triumph of the system, since its component parts do what they are designed to do. Medicaid provides variable support for some of the poor. Medicare offers a finite package of care for the elderly, with patients in the eastern United States receiving 60 percent more care than those in the West. Veterans are cared for in a mini–National Health Service, which appears to have had some success in shifting cases from the hospital to primary care settings. The majority of U.S. workers are offered little choice in insurance plans by their employers, who, confronted by an escalation in costs, increasingly have recourse to higher levels of deductibles and copayments and are pruning benefit packages. Then there are the 43 million Americans with no health insurance. Over the life cycle, the American lottery can move people across these systems with significant consequences for their material well-being and health.
In each of these health care systems, Americans face price discrimination and bankruptcy if they are unlucky in their genes and life events. In their book, Barlett and Steele describe these problems in graphic detail. They explain how, instead of cross-subsidizing the poor with revenues from people who are more affluent, providers charge them higher prices for the same services as those received by the more fortunate. This price discrimination is supported by vigorous pursuit of people who fail to pay their health care debts.
American private-sector bureaucrats, like their public-sector counterparts in Europe, increasingly have recourse to "cookbook medicine," in which practice guidelines and protocols (all too often evidence-free) are imposed on practitioners. Given that medical practice exhibits established and significant variations and well-chronicled medical errors, together with a remarkable reluctance to measure success in improving the quality of life of patients, it is unsurprising that bureaucrats seek to establish quality standards in the health care industry. What is surprising is that their efforts in the United States and elsewhere remain feeble and are rarely "confused" by evidence of cost-effectiveness. But there again, this is no accident but, rather, the deliberate product of the incentive structures inherent in the U.S. health care system. These incentives protect the insurers and providers from contestability, muting price competition and ensuring that competition in quality is superficial and rarely informed by patient-outcome data.
Barlett and Steele offer a nicely documented and well-written insight into all that is bad with the U.S. health care system. For skeptical Europeans on the receiving end of evidence-free health care reforms often inspired by unevaluated policies from the United States, this book is a welcome antidote. There are no simple solutions to complex problems inherent in health care systems worldwide, and the authors' advocacy of national insurance as the solution to the problems of equity and access that they document is unconvincing. First, insurers and providers thrive at the current health care feast and are unlikely to support reforms that redistribute their jobs and incomes. Second, tax-financed national insurance does not address the problems of inefficiency in the supply of health care as demonstrated by Europe. National insurance enables societies to love their neighbors, but as Adam Smith, the 18th-century Scottish economist, noted, capitalists always conspire to exploit the consumer, and nowhere is this more evident than in the health care sector.
Will Barlett and Steele precipitate altruistic reform, unlike their many predecessors who have described the failings of U.S. health care? The recent presidential election makes this unlikely. Americans appear to prefer to practice their religion in isolation from their social policies.
Alan K. Maynard
University of York
York YO10 5DD, United Kingdom
akm3@york.ac.uk(Donald L. Barlett and Jam)