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Clear-Headed Answers to the Obvious Questions

1994; Project HOPE; Volume: 13; Issue: 4 Linguagem: Inglês

10.1377/hlthaff.13.4.227

2694-233X

Theodore R. Marmor,

Healthcare Policy and Management

Book Review Health AffairsVol. 13, No. 4 Clear-Headed Answers to the Obvious QuestionsTheodore R. Marmor AffiliationsPublic Policy and Management at the Yale University School of Organization and Management and a fellow of the Canadian Institute for Advanced Research.PUBLISHED:Fall 1994Free Accesshttps://doi.org/10.1377/hlthaff.13.4.227AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSHealth reformEducationPoliticsClinical careDisputes over public policy in the United States are notably noisy, messy matters. This is the case whether the issue is support for Star Wars or Supreme Court nominees, tax increases or prayer in the schools, welfare reform or universal health insurance. The particular groups and advocates obviously vary, but there clearly is a recurrent process at work.Claims of crisis are used to attract attention, and charges of emotionalism and publicity-seeking follow soon after. Seemingly appropriate statistical aggregates are trotted out: American health expenditures, deficit levels here and abroad, numbers of Soviet missiles (when that was relevant). Estimates of the number of homeless, fearless, fearful, or homely are presented in print, speeches, and interviews as if their particular truth entailed a discrete policy remedy. Fact-throwing begets a familiar form of policy exchange—ridicule for the other side and relief that one's own position is the right answer. Audiences are told that there will be difficulties, of course, but with political will and a modicum of good luck, the nation can choose the course and move toward the desirable state of affairs—lower infant mortality, better education, more effective defense, more readily available drugs, control over Alzheimer's disease, reduced levels of cancer, lower health costs, and on and on. This is the kind of policy talk I call “crisis mongering.”The supply of American problems is by definition enormous. The simple citation of facts can always establish a gap between aspiration and actuality. Compelling, appealing illustrations can demonstrate the character of present difficulties and suggest the crafting of appropriate remedies. “There ought to be a change in the law. There must be something we can do about this,” runs the familiar refrain. Precisely what change and what remedy are right is the real core of the dispute.The recent politics of health care reform are no exception to this pattern. Crisis-mongering, fact-throwing, and heady explications of one remedy after another—all of this has marked the period since Harris Wofford's 1991 senatorial campaign brought America's health problems to the top of the nation's public agenda. The debate has hardly been illuminating. A year after President Clinton presented the product of his enormous task force on reform, the American public is more confused and the legislative context more stalemated than it was before all of this happened.It is in this context that Marc Roberts and Alexandra Clyde's recent paperback deserves special attention. Any citizen puzzled by the feverish claims and counterclaims of what passes for our national health reform debate will find this work a helpful guide to both the disputed problems and the contested remedies.Your Money or Your Life —an unfortunate title that panders to modern marketing— asks all of the obvious questions and supplies clear-headed answers that are in sharp contrast to the technobabble so evident in much of today's commentary on health reform. It begins by dating the sudden reemergence of health troubles on the nation's agenda, rightly noting that while in early 1991 “only 1 percent of the public felt that health care was the nation's most important problem,” less than a year later that same public “ranked it as the second most important issue.” Chapter 2—addressing the “underlying causes of the current health crisis”—attempts to understand the medical care system we have, comparing it to a “swamp” that humans have created but that no particular evil group precisely sought. This chapter is refreshingly analytic, devoted to comprehension, not calumny. It is followed by another analytic effort to make sense of the major institutional actors in American medicine. The authors are especially acute in generalizing about how interests, ideology, and American political structures interact. They make plain the “imbalanced political market” in which particularism is rampant, the already organized advantaged, and the difficulties of putting a “new and alternative future” on the bargaining table enormously difficult. Political scientists have written mountains of articles and books on this subject; few have explained this topic as cogently as Roberts and Clyde have.Taking stock is the focus of chapters 3 and 4, brief descriptions of what does and doesn't work in American medical care and what the alternatives are for reforming that system. What marks the authors' treatment of these familiar subjects is their balanced and historically informed perspective. “The fundamental ethical and practical choices” of health care reform, they rightly note, “have not changed over the past twenty years.” If there were “a simple, proven answer to the nation's health care woes,” they suggest, “health care reform would already have been accomplished.” This sets up a discussion of the range of reforms on the political agenda, sensibly excluding the unrealistic alternatives of unfettered free markets and a British-style national health service. All of this is done in clear, simple prose, specially designed to help us “know a good outcome if we are lucky enough to stumble across it amid the fog created by all the ‘blue smoke and mirrors’ of the Washington debate.”With this as essential background, the book shifts to a series of “special problems,” the details of which will encumber any reform effort: acquired immunodeficiency syndrome (AIDS); malpractice and prescription drug policies; the disputes over covering mental health, dental services, and long-term care; and, finally, the education of physicians and nonphysician medical personnel. The book ends with reflections on whether it is “possible to transform the politics of health care reform” and “achieve a better result.” The authors wryly conclude that “we shall see,” but their book will help anyone understand whatever outcome emerges. Those of us in the health research industry should take special note of this “popular” book, one written to explain complicated matters to a broad sector of society. For all of the scholarship on American medicine, we have had far too few books that take on, let alone accomplish, this important task. The rewards of academic life disproportionately favor original research and peer-reviewed publications. There is for some specialists the comforting but insupportable assumption that works of synthesis are somehow easier, something that anyone can do with a little time and a big enough advance. Paul Starr's magisterial work of the early 1980s— The Social Transformation of American Medicine —did for specialist historical studies what Roberts and Clyde have done for specialist policy analysis. Your Money or Your Life is the sort of book one wishes one had had the wit and capacity to have written. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 1 January 1994 InformationCopyright © by Project HOPE: The People-to-People Health Foundation, Inc.PDF download