Reforming for Quality

Your Money or Your Life by David Cutler (Oxford University Press, 158 pages, $13.95)

The Health Care Mess by Rashi Fein and Julius Richmond (Harvard University Press, 320 pages, $26.95)

If social security is the third rail of American politics, health-care reform is the treadmill. Not quite so deadly, but far more time-consuming and exhausting. An errant leader who tries to touch the pension system gets immediately zapped, but presidents attempting to impose order on the health-care industry fid themselves, after months and even years, exactly where they started and totally spent by the effort.

And yet they keep trying. No other initiative has been taken up so consistently only to fail so regularly. FDR would have liked to include health coverage for all in Social Security but decided it would imperil the whole bill. Harry Truman tried to pass national health insurance but was defeated by ascendant Republicans. By the presidencies of John F. Kennedy and Lyndon Johnson, liberals had decided universal insurance was out of reach and sought only to cover the old and the indigent. Richard Nixon pushed a plan centered on an employer mandate, but Watergate put an end to his efforts. And, most famously and recently, Bill Clinton's attempt ended in a spectacular implosion that hobbled his entire first term.

This history of frustration has attracted more than a few chroniclers. What sets Julius Richmond and Rashi Fein's The Health Care Mess apart from the pack is its expanded perspective. Rather than approaching health as a purely political issue, they detail the evolution of the health-care industry, especially the research sector, teaching infrastructure, and hubs of care delivery. For them, health care is a story not merely of failed political machinations but of new medicines and more advanced treatments. As both were involved in government efforts to expand care during the 1960s and 70s, they're particularly strong when discussing the “bumper crop” of transformative health legislation and failed efforts to achieve universal coverage during that period.

But though their story is well told, it's a history that has been related elsewhere. And considering the many failed policy approaches to universal health care, what may be most needed is fresh thinking on the subject.

That's where David Cutler's Your Money or Your Life comes in. Cutler, a Harvard economist, worked on Clinton's doomed effort and, upon its death, set about reflecting on where they'd gone wrong. His eventual answer was virtually everywhere, but not just in the political sense. According to Cutler, the health-care debate is deeply flawed, myopically mired in issues of cost and access. Both, he grants, are important. But with most Americans able to afford health care, calls for reform based solely on those concerns will continue to fail. The fee-for-service system encourages a reliance on technology-intensive treatments -- the costly procedures that are richly reimbursed by insurers -- while simple, but potentially more valuable, services are often overlooked.

It would be disingenuous to call quality improvement a new idea. It's been kicking around policy circles for decades now, and Clinton's plan incorporated some provisions intended to promote better quality. But quality improvement has not yet emerged as a powerful force in the public debate, and Cutler's book, at a slim 123 pages (without notes) and written in admirably jargon-free prose, seems an attempt to inject it into the conversation.

His argument is simple: A system based on high-intensity care, as ours is, will not only cost more, but deliver care of poorer quality. When unnecessary, surgery is dangerous as well as expensive. An ideal system would pay based on value, the degree of improvement, relief, and safety (medical errors and incorrect procedures take almost 200,000 lives each year) each service or procedure offered to patients. This would require greater standardization, comparative research, and data collection than we currently employ. But with the rise of information technologies, there's no longer an excuse to keep practicing intuitive medicine. The Veterans Administration health system has employed information technology to improve care, reduce errors, and better pinpoint diagnoses, and the system's hospitals now routinely outrank the best private care centers in the nation.

But as trenchant as Cutler's points on approaching medicine are, his suggestions for reform are weak. Despite admitting that private insurance is broken, he offers a vague hope that “bonus payments” for health improvements and risky enrollees can be deployed to end cherry-picking (the practice of seeking out healthy, young applicants and rejecting or pricing out unhealthy, older ones). If Cutler is unconvincing on the policy path forward, however, he is thoughtful and provocative on the foundations of the debate.

And maybe that's the crucial thing. After all, many fine political minds have tried to strategize their way out of this thicket; there's no reason to think we merely require yet finer tacticians. Rather, a fresh perspective may be exactly what the doctor ordered. Conservatives have enjoyed some success in hijacking the debate through the savvy deployment of fresh buzzwords like “Health Savings Accounts” and “Consumer Directed Health Care.” If progressives are to return fire, they will need new weapons of their own, and Cutler may provide some help in furnishing that arsenal.

Ezra Klein is a Prospect writing fellow.

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