Critical Condition: How Health Care in America Became Big Business--and Bad Medicine

by Donald L. Barlett (Author), James B. Steele (Author)

Editorial Reviews

From Publishers Weekly
Bestselling investigative journalists Barlett and Steele (America: What Went
Wrong?) deliver a devastating indictment, supported by excellent research, of a
health-care system that they say is failing to provide first-rate services to
its citizens, 44 million of whom are without insurance. According to these
Pulitzer Prize–winning reporters, now with Time magazine, the U.S. compares
poorly with other Westernized nations in delivering quality care and a healthy
life expectancy, and preventing infant mortality. Per capita health-care
spending continues to exceed the amount spent by many other countries, the
authors say, because one out of every three U.S. dollars pays for administrative
costs. The authors also present case histories of patients, some with
life-threatening conditions, who were ignored by bureaucratic HMOs that put
profit first. Barlett and Steele describe how health care first became driven by
profits on Wall Street during the Reagan administration. Competing insurance
plans, they say, led not to better choices for consumers, but to physicians who
are prevented by insurers from prescribing needed treatments; a severe shortage
of nurses; and unsafe hospitals where staff shortages and unsanitary conditions
result from cost-cutting. The authors, who strongly advocate a single payer
plan, successfully depict a health-care system in crisis.

From the New England Journal of Medicine, March 17, 2005
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.

Product Details

Paperback: 288 pages
Publisher: Broadway (October 11, 2005)
Language: English
ISBN-10: 0767910753



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