American Health Care edited by Roger Feldman

A Book That Should Stimulate a Long-Overdue National Debate

Independent Institute · 2000 · 429 pages · $39.95

Reviewed by Vincent Cangello, M.D.

American Health Care is the work of 15 writers expert in different facets of the health-care delivery debate. I regard it as one of the best books on the problems in our health-care system since Paul Starr’s 1982 prize winner, The Social Transformation of American Medicine.

The contributors have the advantage over Starr of the intervening years of experience gained from government-controlled and privately administered managed-care systems. We have learned much in the last 20 years about the waste and inefficiency generated by government attempts to manage and improve on the market for medicine and health care.

The failure of Hillary Clinton’s Task Force and its proposals for a government takeover of most of our health-care system serves as a backdrop to the book. Editor Roger Feldman (professor of health insurance at the University of Minnesota) writes, “To discover why [Clinton's] health care reform failed, it’s more enlightening to read the popular press than the academic journals. The press intuitively understood that the American People were not willing to entrust the government with running the health care system.” At that point, I knew I was holding a book I had to read.

There are four main sections to the book. Part I addresses health insurance and finance. Ronald Hamowy’s historical review of government-inspired health-care delivery efforts, starting with Bismarck’s Germany in 1883, should be “must” reading for any student of health-care reform. Charlotte Twight’s discussion of the 1996 Health Insurance Portability and Accountability Act made me aware that despite my efforts to stay abreast of the government’s involvement in health care delivery, I failed to appreciate the scope of this legislation. It created a national medical information database and made it possible for the secretary of health and human services to rewrite rules concerning the privacy of individual medical records. “For the common good” will be a new force affecting the privacy of our medical histories. Gail Jensen’s description of medical savings accounts is superb, and Clark Havighurst generates a breath of fresh air for those of us who still want to solve this national dilemma through private enterprise and freedom of contract.

Part II addresses health-care services: the regulation and governance of hospitals, pharmacies, and other health-care services. The six essays in this section shed light on a much-overlooked aspect of government health-care control. To name just two, Michael Morrisey exposes the dirty secret of Certificate of Need laws, which were expected to lower health-care costs but in fact “restricted the entry of new hospitals,” thus limiting competition and raising prices. Richard Epstein writes about the unintended consequences of insurance regulations regarding community ratings and pre-existing conditions.

Part III deals with drugs and medications, with three essays that severely criticize the FDA. Paul Rubin, for example, argues that the FDA’s ban on advertising the health benefits of aspirin “undoubtedly causes tens of thousands of needless deaths per year.”

Part IV examines problems faced by physician and nonphysician providers as they perform their daily tasks; it covers such areas as the quality of care, malpractice liability, professional licensure requirements, and the unintended effect of health-care fees and price controls. One essay, by Shirley Svorny, takes on the “sacred cow” of physician licensing and argues for liberalization to allow nonphysicians to perform more health-care tasks. Another, by Patricia Danzon, calls for reform of medical malpractice laws.

This ambitious book should stimulate the long-overdue national debate that is necessary before sensible health-care reform can be achieved.

Vincent Cangello, M.D., is the director of the Health Care Reform Educational Institute, Oakland, California (, and former professor of health and medical sciences at the University of California, Berkeley.

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