By Uwe E. Reinhardt
Princeton University Press
Even twenty years ago, it should have been clear that the collision of two powerful, long-term trends in our economy would eventually drive the debate on U.S. health policy to the impasse it reached in 2017. Indeed, some of us had predicted it years ago.
The debate is conducted in the jargon of economics and constitutional federal-state relations. But it is not really about economics and the Constitution at all. Instead, at the heart of the debate is a long-simmering argument over the following question on distributive social ethics:
To what extent should the better-off members of society be made to be their poorer and sick brothers’ and sisters’ keepers in health care?
The two ominous long-term trends on which I based my dire prognosis on the uninsured are the following:
- the rapid secular growth in the cost of American health care, in the face of
- the growing inequality in the distribution of income and wealth in this country.
In the early postwar period and through the 1990s, the dream among health policy analysts and the policy makers they advised had been to construct for America a roughly egalitarian, universal health insurance and health care system.
The dream appears to be dead. We will examine the symptoms of its demise throughout the book. Just one example is the ceaseless talk about the economic “sustainability” of Medicare and Medicaid. That argument reflects efforts by some members of Congress and their advisers to construct for the United States an officially sanctioned, multi-tiered health system in which the quality of health insurance and of the health care experience of low-income and lower-middle-class Americans does not have to match the health care experience of families in the upper strata of the nation’s income distribution. In effect, they seek a system in which health care is rationed by income class.
In the rest of the book, I begin with an overview of U.S. health spending and the factors that drive our high health spending. I argue that these spending trends already are pricing more and more American families in the lower part of the nation’s income distribution out of health insurance and health care as families in the upper half of the distribution know it. I then focus on a number of bizarre quirks in our health system that are unique to the United States, explain who actually pays for health care in the United States, and explore the question whether from an international perspective Americans get adequate value for their high health spending.
Part II of the book is devoted to the ethical questions that the current situation in the United States raises for health policy makers. I explain the different distributive ethics different nations impose on their health care systems and how the United States is different from the majority of the rich nations in Europe and Asia in that it has never been able to reach a politically dominant consensus on a distributive ethic for American health care. This is followed by an explanation, from an ethical perspective, of the mechanics of commercial health insurance, which accounts for over a third of the total health spending in the United States. I then turn to focus on health reforms and the ethical precepts that underlay the reforms in recent years. The book ends with a brief novel proposal of my own for the next health reform in the United States.
By Don McCanne, M.D.
We can be thankful that Uwe Reinhardt left with us a concise message of the culmination of his life-long devotion to understanding and teaching the economic and ethical costs of American health care, and he did this in only 137 relatively short pages that constitute the main body of this work. But the story is not the conciseness but rather what we might label the normative economics (he didn’t) of health care. The excerpts from the Introduction (above) provide an excellent guide as to what you can expect from this book.
A very special section is the Epilogue written by Tsung-Mei Cheng – his partner in health policy but, more importantly, his partner in life. She provides a clarification of some of his teachings as only she could understand. Of particular interest for single payer advocates is his sometimes confusing expressions as to how single payer may be a great system for some other nations (e.g., Taiwan, which can be thankful for the partnership of Tsung-Mei Cheng and Uwe Reinhardt in advancing health care justice in that nation), yet why he did not consider single payer appropriate for the United States.
For a spoiler that isn’t a spoiler, I will say that his Conclusion – a novel reform proposal of his own – is in the classic teaching style of Uwe Reinhardt. He has said many times before, “Tell me what you want (primarily the ethics of a health care system) and I can design for you a system that will do that.” In this book, he has described the economic and ethical costs of the system that we have chosen, by action and inaction, and used that to offer up reform that would perpetuate our expressed, uniquely American values that have resulted in the system we have. Although it need not be said, it is a teaching lesson, and his unspoken homework assignment is for us to prove him wrong.
In summary, Tsung-Mei Cheng begins her Epilogue with the following:
“The issue of universal coverage is not a matter of economics. Little more than 1 percent of GDP assigned to health would cover all. It is a matter of soul.”
– Uwe E. Reinhardt
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