Who Shall Live?

The following sections are included:

• CONTENTS

• PREFACE TO THE EXPANDED EDITION

• PREFACE TO THE PAPERBACK EDITION (1982)

• ACKNOWLEDGMENTS

The problems are all around us: a mother searching frantically for someone to see her sick child; a crippling disease that puts a family hopelessly in debt; a tenfold increase in deaths from emphysema since 1955; a doubling of Blue Cross rates in just a few years. The list could be extended almost without limit….

The following sections are included:

• The Problems We Face
  • COST
  • ACCESS
  • HEALTH LEVELS

• The Choices We Must Make
  • HEALTH OR OTHER GOALS?
  • MEDICAL CARE OR OTHER HEALTH PROGRAMS?
  • PHYSICIANS OR OTHER MEDICAL CARE PROVIDERS?
  • HOW MUCH EQUALITY ? AND HOW TO ACHIEVE IT?
  • TODAY OR TOMORROW
  • YOUR LIFE OR MINE?
  • THE JUNGLE OR THE ZOO?

Good health and long life have traditionally been among the most prized goals of mankind. In every age and in every land there have been significant efforts to postpone death, whether through sacred dance and song, the imbibing of magic potions, or the application of the most modern medical techniques….

More than 4½ million men and women from some two hundred occupations are employed in the delivery of health services in the United States. One type of health professional—the physician—plays a unique role. Although physicians account for only 8 percent of health service employment, their actions and decisions are of critical importance to the entire system. The term “health team” is sometimes only a figure of speech, but the “captaincy” by the physician is beyond doubt. It is impossible to understand the problems of medical care without understanding the physician. And it is impossible to make significant changes in the medical field without changing physician behavior….

The American hospital is large, impersonal, and dominated by elaborate technology. The American hospital is small, inefficient, underequipped, and understaffed. The American hospital exists primarily to further the professional and economic interests of physicians. The American hospital exists to serve the community. The American hospital is crowded to the point of inefficiency and even danger, and serious delays are encountered in obtaining admission. The American hospital is often half-empty, and many of its patients should be at home or in extended-care facilities. The American hospital is the noblest expression of the philanthropic impulse. The American hospital is a business run to show a profit for its owners….

Drugs are the key to modern medicine. Surgery, radiotherapy, and diagnostic tests are all important, but the ability of health care providers to alter health outcomes—Dr. Walsh McDermott’s “decisive technology”—depends primarily on drugs. Six dollars are spent on hospitals and physicians for every dollar spent on drugs, but without drugs the effectiveness of hospitals and physicians would be enormously diminished….

How to pay for medical care? This question, which periodically has been the subject of vigorous debate in the United States for more than half a century, has moved to the forefront of public attention in the wake of rapid increases in the cost of care and heightened concern about inequality of access. More than a dozen different proposals for some type of national health insurance have been submitted in Congress, and major interest groups—private insurance companies, hospitals, organized medicine, and organized labor—have staked out their positions in great detail. Before considering the pros and cons of national health insurance and the implications of alternative proposals, a few general remarks about medical care finance and the present U.S. system are in order….

In the preceding chapters, I have discussed the major problems of health and medical care now facing the American people and have delineated the different social choices that must be made. These problems—high cost, inadequate access, and unsatisfactory health levels—have been examined from the economic point of view, which stresses the need to allocate scarce resources efficiently in order to best satisfy diverse human wants. For most Americans, better health is not the only, or even the most important, goal. For most Americans, more medical care is not the only, or even the most promising, route to better health….

The Great Health Care Debate of 1994 was like the uses of this world to Hamlet—“weary, stale, flat, and unprofitable.” Why did so much effort by so many produce so little understanding and no reform? The finger of blame has pointed in many directions: “the Clinton Plan was unworkable”; “the plan was poorly explained to the public”; “the political strategy was misconceived”; “special interests triumphed over the general interest.” Each of these explanations has some merit, but I believe the fundamental reason has been the unwillingness of policy makers and the public to make the difficult choices that are inevitable if the U.S. is to improve its approach to health care. What are the difficulties?

Gertrude Stein, noted author and confidante of the leading writers, artists, and intellectuals of her time, lay dying. Her closest friend and lifetime companion, Alice B. Toklas, leaned forward and said, “Gertrude, what’s the answer?” Gertrude looked up and with her last breath said, “Alice, what’s the question?”…

Almost a century ago Prince Otto Eduard Leopold von Bismarck, the principal creator and first chancellor of the new German nation-state, introduced compulsory national health insurance to the Western world. Since then, nation after nation has followed his lead until today almost every developed country has a full-blown national health insurance plan. Some significant benchmarks along the way are the Russian system (introduced by Lenin after the Bolshevik Revolution), the British National Health Service (Beveridge and Bevan, 1945), and the Canadian federal-provincial plans (hospital care in the late 1950s, physicians’ services in the late 1960s). In nearly all cases these plans built on previous systems of medical organization and finance that reflected particular national traditions, values, and circumstances.¹…

Proposals for national health insurance are once again making the headlines, as they have periodically in the United States since World War I.² Advocates of national health insurance have, as always, diverse goals: to expand access to health care for millions of uninsured Americans; to stem the rapid escalation in the cost of health care; and to improve the overall health status of the population and reduce socioeconomic differentials in life expectancy. Vigorous opposition to national health insurance is not a new phenomenon. Insurance companies, physicians, and others directly involved in the health field see national health insurance as a threat to their roles and interests; in addition, many Americans with no direct involvement in health issues oppose expansion of government on general principle. The huge federal budget deficit contributes to the difficulty of enacting a major new domestic program, in health or any other area. Thus, the debate among those for and against national health insurance does not appear to be headed for resolution any time soon.…

A scholar, wrote George Stigler, winner of the Nobel Prize in economics, “ought to be tolerably open-minded, unemotional and rational. A reformer must promise paradise if his reform is adopted. Reform and research seldom march arm in arm.” ¹ As a longtime researcher and teacher about America’s health care system, I congratulate President Bill Clinton, Hillary Rodham Clinton, and their aides for the phenomenal job they have done in getting the nation to focus on health care. The current problems are so big and complex partly because of the unwillingness or inability of previous administrations to address them. The Clintons deserve praise for their courage and their skill in bringing health policy to the top of the domestic agenda. I also applaud them for giving priority to universal coverage and for their recognition that universal coverage requires subsidies for the poor and the sick, and compulsion for those who can obtain insurance but choose to “free ride” instead. Commendation also is in order for the Clintons’ insistence that the gap between the rate of growth of health spending and the rate of growth of the rest of the economy must narrow. Finally, I believe that they are on the right track in encouraging the formation of integrated health care plans that will have responsibility for defined populations.…

Interest in health economics has soared over the past three decades, stimulated by intellectual innovations, greater availability of data, and, most importantly, a surge in health care spending from 6 to 14 percent of GDP.¹ An eleven-fold increase² in the number of Ph.D.s has enabled many professional schools, government agencies,³ and research institutes to add health economists to their staffs. Nevertheless, the health care debate of 1993–1994 benefited much less than it could have from the results of their research.…

The following sections are included:

• Notes

• Index