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Commentary

Mismanaged Care
Sally Satel, MD, The New York Times Book Review, 4-8-07

Satel, a senior fellow at the American Enterprise Institute, reviews a new book on health care by Jonathan Cohn, an editor at the The New Republic.

The hand-picked subjects in "Sick" don't reflect the full range of causes for so much poor health in this country, many of them rooted in inertia: not watching one's diet or exercising, drinking to excess, smoking. Cohn's victims are in almost every instance hardworking, conscientious people blocked at every turn by a dysfunctional system. Thus, even as he vividly brings them to life, Cohn cautions that their stories "are not so much representative as indicative," meant to show the perils faced by people "when their need for medical care overwhelms their ability to pay for it." But "Sick" is much more than a meticulously drawn and moving compilation of crises.

It is also an edifying primer on how we got here. To fine effect, the author weaves summaries of health care history into the case studies. He traces the developmental arcs of key institutions, like private insurance, employer–linked insurance, managed care, religious hospitals and corporate health care. We see Blue Cross and the first prepaid group practice in the bloom of their youth when idealism was high and implementation relatively straightforward. They flourish for a while but then decline under the weight of a troubled manufacturing economy, bottom–line imperatives of corporate health care, the rising cost of medical technologies and changing definitions of what constitutes basic benefits.

Cohn also reminds us that efforts to enact a national health policy have been a staple of presidential politics in the past century. In the 1930s Franklin D. Roosevelt wanted to pursue a universal health insurance plan (as Theodore Roosevelt had done during his failed presidential bid in 1912, although Cohn doesn't mention it) but feared opposition from the American Medical Association and from state medical societies. Harry S. Truman had the same idea, only to meet resistance from union leaders concerned that members' benefits would decrease under a national system. A quarter–century later, President Nixon proposed an employer mandate to insure workers, and in the early 1990s we lived through the drama (and trauma) of President Clinton's thwarted reform effort.

"Sick" does not offer a prescription for our ailing health care system, but it does include a closing chapter on what to do. Here the argument turns tendentious. Critics of universal coverage, Cohn writes, often traffic in alarmist tales "about rationing and waiting lines, followed by a horror story from Britain or Canada." Those complaints are "wildly exaggerated" and also unfair, he says, because the problem is not the result of universal health care but "of universal health care on the cheap."

But Cohn is himself being unfair when he sweepingly denounces "the principles of modern conservatism" for being "conspicuously short on ... comfort or hope." In truth, there is nothing inherently pessimistic in choice, self–reliance or limited bureaucracy—the values that underlie a market–based proposal like the one introduced by Senator Ron Wyden, an Oregon Democrat.

In this plan, employers would no longer provide insurance and would instead convert those costs into a bigger paycheck, enabling workers to buy private insurance from providers who would then be forced to compete for business by offering better plans. (Wyden's proposal also offers subsidies for the unemployed.)

Cohn prefers the French health care system, calling it the "showcase for what universal health care can achieve." His brief description does indeed make the French model, which is largely single–payer, look attractive. But since we are not given enough details—an inevitable feature of a book that devotes only a fraction of its content to solutions—the reader is left to take the author at his word.



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