The House of Hope and Fear: Life in a Big City Hospital Review

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(More customer reviews)Dr. Young's new book is an engaging account of life at the large mission-driven county hospital in Seattle. I spent most of my 3rd year med school rotations there myself 12 years ago and am now working in a mission-driven community health center 18 miles away. My desire to serve the poor was a direct result of the dedication from the doctors and staff that I witnessed at Harborview. Now, I spend more than half my time educating and mentoring medical students and I plan on incorporating this book into our 2nd year curriculum.
The stories are diverse: some are about incredible patients and their challenging situations - socially, medically, psychologically; some are really more about the ethical dilemmas faced by providers, and faced by patient's families; other stories point out the inequities in healthcare, while demonstrating how this institution has creatively found a way to thrive financially while serving the least able to pay.
Most importantly to me - this book is hugely interesting, well written, easy to read, hard to put down and deserving of high praise. The reason this book is so good and the messages conveyed so well is that Dr. Young has incredible skill at portraying the humanity of her subjects. This is a book of true characters; unforgettable characters. The characters are patients, their loved ones and families, the infamous ER director, a remarkable specialist in nephrology, Dr. Young herself, and the staff of the hospital. I read their stories and can picture them on a gurney, in their offices, on the wards, in the ER; I can smell the smells again; and hear the sounds in the ICU.
This text can easily and effectively (each chapter is pretty well able to stand on its own as a separate reading - though together it reads as a cohesive story) be used regularly with medical students and public health and policy students - the examples in it are perfect for igniting debate about healthcare inequality, social justice, medical ethics, professional development, difficult patients, allocation of resources and care for the underserved.

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Opening with the view of an idealistic, young doctor entering her first post-graduate job at the local county hospital, The House of Hope and Fear explores not only the personal journey of one doctor's life and career, but also examines the health care system as a whole. The county hospital setting provides the author with a second education. With clear, eloquent text, she chronicles attempts made to treat those tossed aside by society along with the personal and ideological shifts that accompany this daunting task. All of the political aspects of the hospital's executive board are detailed in a gripping account of the hospital's inner workings, and a human face is expertly given to the healthcare crisis in America.

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Experiencing Politics: A Legislator's Stories of Government and Health Care (California/Milbank Series on Health and the Public) Review

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(More customer reviews)Former Massachusetts state legislator John McDonough takes readers from the theory to reality of practical politics in a surprisingly unegotistical fashion. He uses various theories about why and why political actors do what they do as they go about their business to introduce his own experiences.
The obligatory academics (the book is a valuable text book as well as a good read) are clear and easy to get through. The political stories are particularly informative and of great interest to people who want to know some of the 15,000 ways and by-ways that bills can travel to become law.
Experiencing Politics is instructive and should be required reading for zealots who'd rather make a point than make a difference. Of particular interest to all the victims of Narcissistic Advocates Personality Disorder (the Nader types, the zealots, the self righteous as only the Boston/Cambridge axis can breed) are McDonough's experiences and observations as an advocate for housing and as one who tried to ameliorate the impact of the loss of rent control.
Massachusetts political junkies and students of legislative process should love this book. McDonough doesn't describe his role as that of savior or saint, but as an interested student and practitioner of practical progressive politics who wants to be a player in his legislature.

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Going Up the River: Travels in a Prison Nation Review

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(More customer reviews)Over the last 20 years, America's prison population has exploded. We now incarcerate about 2 million people--a higher rate than any other country in the world. Mr. Hallinan takes us on a tour of the prisons that hold this growing population...and serves up a unique view point.
When readcing Going Up the River, one must remember that the author works for the Wall Steet Journal. With this "day job" it is not surprising that Mr. Hallinan delves into a side of the prison boom not often examined: the costs, who pays them, and who profits?
Everyone seems to admit that prisons do not rehabilitate anyone. They are so large, so poorly funded, and so violent, that the only realistic goal of either the prisoners or the gourds is to come out alive. As Mr. Hallinan says, anything beyond survival is clearly a luxury in today's prisons.
So, if prisons are not doing their job, then why are they so popular?
Mr. Hallinan's answer is that the prison boom has been accompanied by (or was caused by?) a redefinition of the very concept of a prison. No longer viewed as a place to incarcerate and reform or rehabilitate, prisons are now viewed as a source of economic development, jobs, and patronage.
His story of the building of Tamms--Illinois Supermax--is illustrative. Built in a small, impoverished, southern Illinois town approximately 365 miles from Chicago, the prison was expected to be an economic engine. As it was being built, the local housing market exploded, restaurants opened, etc. At the same time, the county--which had gone democratic in state-wide races for decades, voted republican 2-1 after the Republican governor announced the new prison.
What the author missed is the end of the story. After being open two years, Tamms has seen virtually no benefit from the prison. The new restaurants are closed. The new jobs went to experienced guards living elsewhere. The real estate market in Tamms is as depressed as ever.
The question Mr. Hallinan asks at the end of his book is the right one--has America's addiction to prisons begun to wane? Only time will tell, but the story of Tamms suggests that they ain't all they're cracked up to be as engines of economic development.
An excellent book, highly recommended for anyone who cares about crime or prisons--but an absolute must read for anyone who cares about taxes!

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The Fluoride Deception Review

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(More customer reviews)With the futile search for Iraq's weapons of mass destruction some Americans may just now be realizing that our government lies to us. The Fluoride Deception documents a cover-up perpetrated by a military-industrial-government complex starting in the 1930's and extending to the present day. Any person involved in the issue of fluoridation will want this excellent compendium of the history and science. The author has uncovered previously secret documents which reveal that fluoridation promotion is in the same league with "cigarette science" when it comes to distortion of science and public opinion.
After documenting all the scientific evidence for why fluoridation is a bad idea, a common response has been: "If it's so obviously bad, why do my dentist, the Surgeon General, and my toothpaste company all say it is so wonderful?" Bryson's book gives the answer. A powerful group of industries have worked behind the scenes to sell the idea of fluoridation. Their public relations campaign has been one of the most successful in history.
I long took for granted that fluoride was the reason I had much better teeth than my parents. I grew up with Crest toothpaste commercials repeating their "Look mom, no cavities!" message into my young impressionable mind ad nauseum. But not too long ago I found that rates of cavities have dropped precipitously in all industrial countries of the world over the past 50 years and most of these countries do not fluoridate their water. Countries with detailed public health records reveal the decline started before fluoride was ever added to toothpaste or water.
Bryson has uncovered secret government and industry documents showing that the aluminum, steel, atomic weapons, phosphate fertilizer, and other industries all have been aware for more than 50 years that one of the most serious and costly pollutants these industries release is airborne fluorides. The cold war obsession with building ever more nuclear weapons to win the "arms race" cemented cooperation between government and industry to promote fluoridation. The US Public Health Service during the 1940s was still a division of the Department of Commerce and its head was a top attorney for Alcoa. Bryson found meetings and letters between the military, Public Health Service, and industry where the idea of putting a shiny public relations image on fluoride by adding it to water first surfaced.
With today's increasing revelations about drug industry manipulation of science and government campaigns of deception, maybe the time is ripe for Bryson's book. Some people won't be willing to believe that their own dentist may have been duped. They won't feel comfortable reading this book. But for everyone curious enough to glimpse into the dark side of science manipulated for profit, this book is for them.
For environmentalists this book is as essential reading as Rachel Carson's Silent Spring.
For dentists and public health officials ... gather up your courage and read this book.

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With the narrative punch of Jonathan Harr's A Civil Action and the commitment to environmental truth-telling of Erin Brockovich, The Fluoride Deception documents a powerful connection between big corporations, the U.S. military, and the historic reassurances of fluoride safety provided by the nation's public health establishment. The Fluoride Deception reads like a thriller, but one supported by two hundred pages of source notes, years of investigative reporting, scores of scientist interviews, and archival research in places such as the newly opened files of the Manhattan Project and the Atomic Energy Commission. The book is nothing less than an exhumation of one of the great secret narratives of the industrial era: how a grim workplace poison and the most damaging environmental pollutant of the cold war was added to our drinking water and toothpaste.

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The health debate: Policy & Politics in the Twenty-First Century (Policy and Politics in the Twenty-first Century Series) Review

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(More customer reviews)This is an important analysis of the mismanagement of the UK NHS in the last twenty years. The UK NHS is both a good example and a dire warning to the rest of the world. It's a good example in that we achieve population coverage to some level. The dire warning bit is that the standards (of access, and outcomes achieved) are not as high as we like to think, or as good as in comparable European countries.
Imagine a car company that did not like its engineers. That's about the relationship between NHS management and the doctors and nurses who deliver the care to patients. Hunter clearly shows the problems that such an attitude causes and reminds us, ""As any change management text will state, the chances of ensuring that successful implementation occurs are seriously impaired if those working on the front line are not signed up to the changes and seek to contest, or undermine them.....A key feature of the most recent changes in the NHS in England is that the key professions have been disengaged from the reform process"
The UK NHS is a dire warning to others. It has consumed vast amounts of policy ideas and money, and delivered little in return for all the investment spent on it. The processes of change have been disruptive, faddy, and not sustained rather than constructive with long term outcomes in mind. Hunter describes the policies and their botched implementation carefully, and is clear about the consequences. The book is clearly written and well referenced, and so makes a strong case for its conclusions.
The tragedy is that all of us are suffering from this- doctors, patients, managers, voters, taxpayers, politicians.
Read this excellent book to find out where things have gone wrong in the NHS and why. And then make a note that centralized top down schemes which do not engage the workers will never succeed. No matter how much you paid the management consultants and special advisers to write them.
And if Americans are looking for a scheme to emulate then the UK NHS probably is not it.

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Exploring Social Insurance: Can a Dose of Europe Cure Canadian Health Care Finance? (School of Policy Studies) Review

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(More customer reviews)I picked up this book as an after thought because right of the bat it seems dense and wordy (which it is). I was thinking I'd skim through the chapters to catch the gist of what was written - however I was pleasantly surprised at the quality of writing (this book has been well edited). This is a great collection of individual work created by various academics/contributors. The basic premise of the book is an investigation into the question of : "Can social insurance be made a part of the Canadian health care financing framework ? ".
The book has arguments for and against this question. Reading well researched and clearly expressed opinions from both sides of the debate was a refreshing change from the usual text of this nature which only talks about one point of view (the authors) ! The book does not give a definite answer , rather I felt it was allowing the reader to create his own opinion (at least I was inspired look at other debates in the US and UK systems).
Great book and highly recommended.

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Sustainability, quality, and accessibility are vital questions in health care. All Canadian governments, concerned about the growing share of the public budget absorbed by health care, are questioning the sustainability of the present system. How can we maintain and improve access to health care services of appropriate quality while ensuring sustainability? If there is one consolation to Canadian governments as they wrestle with the future of Medicare, it is that sustainability concerns are not unique to Canada but affect all countries, regardless of the level of private financing in a system. Some countries, however - particularly social insurance countries in Northern Europe such as Germany and France - manage to achieve universal access without wrestling with waiting lists, while providing a wide range of services. This book examines whether the grail of sustainability, quality, and accessibility could be better achieved through a marriage of the traditional Canadian model with elements of a European system.

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Best Care Anywhere: Why VA Health Care is Better Than Yours Review

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(More customer reviews)Philip Longman makes the case that current U.S. healthcare is a fragmented, market driven system that lags behind much of the industrialized world in both quality and access of healthcare. According to Longman, the problem with our healthcare system is that it isn't really a system and that it doesn't reward the one thing that it should - health improvement. In fact, he offers proof that in the U.S. doctors and hospitals are rewarded for providing treatment, but not necessarily providing health to their patients. To illustrate this, he offers examples from two of the nation's premier hospitals - Beth Israel and Duke Medical Center. Both initiated programs that were so successful at improving health that they became unprofitable and were ultimately terminated.
This book is filled with understandable, but often shocking statistics. For example, every year in the United States 98,000 people die due to medical errors while in the hospital, another 90,000 die due to infections that they get while in the hospital, and 126,000 needlessly die because their doctor failed to use evidence-based protocols for just four of the most common conditions.
The solution? Longman speaks effusively about the VA healthcare system. And rightfully so. It is the only fully functioning, evidence-based healthcare system in the country. The book explores the history of the VA and speaks honestly about some of the warts that mar the VA's reputation. But the truth of the matter is that the VA has turned all of that around and is currently at the front of the healthcare revolution.
Longman's book contains sections on safety, quality improvement, the concept of lifetime healthcare, and the Kizer Revolution at the VA, which dramatically improved quality and altered forever the course of veterans' healthcare.
The section on VistA, the software program that is revolutionizing healthcare, is worth the price of the book. This open source software program is really a bundle of 20,000 programs written in open source code. Surprisingly, it is being adopted extensively around the world - but not right here at home.
Longman proposes a reform of the U.S. healthcare system that incorporates the best of VistA and many other VA best practices and innovations. If you are interested in the healthcare debate and what is possible in future U.S. healthcare, I highly recommend this book.
For those interested in learning more about the healthcare debate and want to explore other opinions, I would also recommend the following three books: A Second Opinion: Rescuing America's Health Care; Who Killed Health Care?: America's $2 Trillion Medical Problem - and the Consumer-Driven Cure; and Redefining Health Care: Creating Value-Based Competition on Results.

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The long-maligned Veterans Health Administration has become the highest-quality healthcare provider in the United States. This encouraging change not only has benefited veterans but also provides a blueprint for salvaging America's own deeply troubled healthcare system. "Best Care Anywhere" shows how a government bureaucracy, working with little notice, is setting the standard for best practices and cost reduction while the private sector is lagging in both areas. Author Phillip Longman challenges conventional wisdom by explaining exactly how market forces work to lower quality and raise prices in the healthcare sector, and how U.S. medical practices have a weak basis in science. The book, expanded from a widely praised article in the "Washington Monthly," mixes hard facts with author Philip Longmans' compelling human story of the loss of his wife to cancer. Part manifesto, part moving memoir, "Best Care Anywhere" offers new hope for addressing a major problem of contemporary society that affects all of us.

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Obama Health Law: What It Says and How to Overturn It (Encounter Broadsides) Review

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(More customer reviews)A key point made by Betsey McCaughey is that there is no reason for a health care bill to be roughly two thousand pages long. "Twenty pages should be enough," declares the former lieutenant governor of New York. This relatively short pamphlet is of great value to those who need to quickly get a handle on the current crisis. We have the best health care of any large country in the world. The medical professionals living in the United States also lead in the effort to develop new medicines. ObamaCare threatens our freedoms---and ultimately the health of our loved ones. We will also be financially bankrupt. Everyone should heed McCaughey's great advice. It might also behoove you to purchase a number of copies to give to your relatives and friends.


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Doctors of Conscience: The Struggle to Provide Abortion Before and After Roe V. Wade Review

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(More customer reviews)This book makes it clear that the Doctors who provided abortions when the procedures were still illegal risked their medical credentialing and professional standing. If they had been discovered, including by an office worker, they could have lost that license or gone to jail. Wanting women to have control over our own lives and access to health care was illegal
And today, my generation finds itself in an interesting paradigm. Because while the state officially allows the performance of abortion, protestors take it upon themselves to hunt and terrorize the doctors who perform this procedure. This climate has chilling repercussions because 86 percent of American counties now lack a medically licensed abortion provider. Wanting women to have access to health care places their lives physically at risk.
With all of the news stories about clinic protests and doctor shootings, it's easy for American citizens to become discouraged, feeling like extremists are winning. But this book gave me effective 'pain relief' by reminding me that we are not alone. There are doctors wanting us to obtain health care.


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Environmental Cancer-A Political Disease? Review

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(More customer reviews)Fear of the unknown is perhaps one of the greatest fears mankind faces. Environmental activists capitalize on that fear; and, magnified by media, especially Main Stream Media, congress reacts creating laws which lead to regulations leveled on industry that far exceed the risk they purport to control. Meanwhile the greatest cancer risks involve lifestyle, free choices made by free people apparently oblivious to, or uncaring, about the risks they subject themselves to on an everyday basis.
With clarity and brevity the authors describe their research regarding the causes of cancer in Americans and compare the opinion of experts (defined as cancer researchers) to those of environmental activists, the media and the public. In all cases the opinions of the experts are diametrically opposed to those of the activitsts which mirror the media's portrayal of the cancer risks Americans face.
The authors concisely lay out their premise and describe the replicable research they did to arrive at the conclusion that Environmental Cancer is indeed a political disease. This book is must reading for anyone trying to understand the basics of cancer risk in America and the implications of continuing to regulate based on fear not facts.

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An examination of the controversies surrounding environmental cancer. The authors draw on surveys by cancer researchers and environmental activists to reveal differences between the two groups' viewpoints. They examine these opposing views and document how they are reflected in the media.

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Sex, Science, and Stem Cells: Inside the Right Wing Assault on Reason Review

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(More customer reviews)I've been reading about issues in bioethics for years, and the title of this book (before I noticed the subtitle) was what got me to pick it up and check it out. I'm quite interested in the ethical issues (and resultant political controversies) surrounding hESC (human embryonic stem cell) research, abortion, and birth control which has contragestive effects (i.e., birth control which prevents a zygote from implanting in the uterine lining). This last is a thorny issue because those on the right, who maintain that a pregnancy begins at conception, classify these methods as abortifacients. On the other hand, those on the left have adopted a different definition which classifies pregnancy as beginning at implantation, and therefore they call these forms of birth control emergency 'contraception'. As another reviewer pointed out, the author seemed (astonishingly) to accuse her political opponents of making up the word 'abortifacient' - which is the term for substances which can cause an abortion and which is a pretty common word in the context of reproductive pharmacology. (The drug RU486 is an abortifacient, but before abortion was as easy to procure as it is today, unwanted pregnancies were often ended with herbal abortifacients. Ophelia refers to this in Hamlet.) It's ironic that she makes this blunder in a book whose thesis is that she is scientifically well-informed, whereas her opponents are ignorant.)
I can't fault her too much for not addressing the important question of replacing hESC research funding with iPSC (induced pluripotent stem cell- which are produced without the use of embryos) funding, because the major breakthrough only was made about ten months prior to her book release. Incorporating the new results and changes in how we think about stem cell research might have required rewriting the entire book. Of course, even at the time when she was writing the book it was clear that in terms of actual treatment of illness, it was adult stem cells and not embryonic ones which were providing treatments. Embryonic stem cells were/are so important because of potential treatments or cures which might be produced using them. To point out that iPSC research is now seen as possibly even more promising than hESC research (when her whole charge was that the supporting the destruction of embryos is justified by its unique promise of future treatments) would have blown a hole in her argument. This is particularly true given that the new method of producing stem cells is one whose funding has been championed as an alternative by those who oppose research which destroys human embryos. (It's too bad for her that she hadn't published a year earlier.)
The review from the 'Daily Camera' is laughable. What this most decidedly is NOT is "a probing philosophical work".
She portrays the ethical controversies as merely a situation in which she and like minded people who are scientifically literate are doing what any rational well-informed person would choose to do, whereas her opponents are either ignorant, or too ideologically extreme, or naive believers in religious and superstitious nonsense (or some combination of these) and cannot see that they are preventing society from advancing into new frontiers of knowledge and health. She completely ignores the fact that her opponents are a coalition motivated by a variety of values (granted- many of them values associated with their chosen faith) who take positions which actually are rational and logically consistent, but which follow from different ethical and philosophical beliefs than those she begins with.
For example, providing emergency contraception to those who may want it, and thereby preventing unwanted pregnancies and unnecessary abortions sounds like a reasonable thing to do, but that is all premised on a particular set of assumptions (like what 'contraception' is, how you define 'pregnancy'- and most fundamentally, what is a 'human being'.) It does not sound reasonable to say that after years of abiding by the compromise language of the Hyde Amendment (which prohibits federal money from being spent on abortions), those in congress who oppose abortion because they believe it kills a human being should get the government involved in providing abortifacients in order to prevent surgical abortions. From the first point of view, one is proposing the use of contraception to prevent a set of circumstances which might require an unpleasant and guilt-inducing medical procedure. From the second point of view one is being asked to weaken a policy which was designed to prevent the killing of innocent human beings based on the argument that killing with chemicals is acceptable where surgical killing is unacceptable.
The author doesn't actually address the bioethical arguments at all, but disposes of them by advocating her side and pretending that there is no other side. This is the sort of political point scoring that makes everyone hate bloviators on FOX News and MSNBC. Then again. if you only hate the former, and you like the latter, you may actually enjoy this Pelosi and Planned Parenthood endorsed portrayal of the progressive Democrats in the House fighting the good fight against the "right wing anti-choicers" during the G. W. Bush administration. Of course, if that's what you like, you'd be just as well served if you went and read some back issues of The Nation.

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Market-driven Health Care: Who Wins, Who Loses In The Transformation Of America's Largest Service Industry Review

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(More customer reviews)No one will accuse Ms. Herzlinger of being a great writer, but her conversational style is easy to read and she does have some good ideas for how the healthcare industry should be. Ideas that still haven't been implemented even now, 8 years after it was written. She does make a fairly convincing argument for how focused factories could reduce costs. In addition, suggestions that everybody should have health insurance, that healthcare providers should not be insulated from market forces, that consumers are the ones with the real power to stop the soaring healthcare costs, and that they'll only curtail spending when given incentive to do so are good points that can't be made often enough. Points that seem even more relevant today given the continued increase in healthcare costs, the inability of the HMO system to manage them, and the spiraling problem the growing uninsured population is creating (the more uninsured people there are, the more insurance costs, which increases the number of uninsured, etc.). She has good ideas, I think it's time people listened. It's of vital importance that the healthcare system incorporate what's great about America, what has made America a leader in every other industry: innovation and sensibly regulated free markets. Ms. Herzlinger gives us a good way to get it done.
I also have to ask if some of the other reviewers actually read the book. The author gives a pretty good analysis of how focused factories would reduce costs, using that 20% of the people produce 80% of the costs as a cornerstone of her argument. Also, she cites physicians' inability to deal with market forces as a cause of the problem and gives suggestions for how to deal with it.

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Tobacco War: Inside the California Battles Review

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(More customer reviews)I could hardly put this book down. The battle being fought is truly a life and death matter, alliances and strategies evolve on both sides, and the Tobacco Industry uses their multi-million war chests to mislead the public over and over and over again. Even when you think you can relax after a victory by the anti-tobacco forces, in the next chapter the Tobacco Industry is lurking behind yet another door with a butcher's cleaver, which ends up being wielded by tobacco funded politicians and the California Medical Association to cut tobacco education funds and to weaken the anti-tobacco media campaign. Really this book is about much more than California and its battle with the tobacco industry. It is the best book I've ever read about why we need campaign finance reform and effective sunshine laws. You are shown all the nitty-gritty details, the back room deals, the closed-door bargaining. You'll emerge from this book well-prepared to detect lies in future wars, and to read between-the-lines in daily newspaper coverage.

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Tobacco War charts the dramatic and complex history of tobacco politics in California over the past quarter century. Beginning with the activities of a small band of activists who, in the 1970s, put forward the radical notion that people should not have to breathe second-hand tobacco smoke, Stanton Glantz and Edith Balbach follow the movement through the 1980s, when activists created hundreds of city and county ordinances by working through their local officials, to the present--when tobacco is a highly visible issue in American politics and smoke-free restaurants and bars are a reality throughout the state. The authors show how these accomplishments rest on the groundwork laid over the past two decades by tobacco control activists who have worked across the U.S. to change how people view the tobacco industry and its behavior. Tobacco War is accessibly written, balanced, and meticulously researched. The California experience provides a graphic demonstration of the successes and failures of both the tobacco industry and public health forces. It shows how public health advocates slowly learned to control the terms of the debate and how they discovered that simply establishing tobacco control programs was not enough, that constant vigilance was necessary to protect programs from a hostile legislature and governor. In the end, the California experience proves that it is possible to dramatically change how people think about tobacco and the tobacco industry and to rapidly reduce tobacco consumption. But California's experience also demonstrates that it is possible to run such programs successfully only as long as the public health community exerts power effectively. With legal settlements bringing big dollars to tobacco control programs in every state, this book is must reading for anyone interested in battling and beating the tobacco industry.

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The Healthcare Fix: Universal Insurance for All Americans Review

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(More customer reviews)
Book Review: The Healthcare Fix
Laurence Kotlikoff is an economics professor at Boston University. Mr. Kotlikoff thinks he's the Man with the Plan for universal healthcare in the U.S. The book he's written is a short, fast read which presents a straightforward message:
Medicare and Medicaid, because of their billing policies are bankrupting the country by feeding healthcare inflation. The fix, according to Kotlikoff is to scrap the two federal programs and replace them with universal health adjusted medical insurance vouchers. A young healthy individual would receive a small voucher say $5000 per year while an older less healthy individual would get a voucher of say $50,000 to buy a full private insurance policy.
This would incentivize private insurers to write policies for these insured as follows. If the oldser only needed $10,000 in health spending for the year the insurer profits by $40,000. OTOH if the youngster was hit with a $30,000 medical expense the insurer would take a -$25000 hit. The latter is less likely than the former. Also, the vouchers would be health history adjusted so that the older patient might get a lower voucher for having a good year.
What's attractive about Kotlikoff's fix is that the voucher system has a built in mechanism for monitoring spending, it eliminates cherry picking of patients and it's universal. However, as is the case with a short somewhat glib book Kotlikoff glosses quite a bit. He even glosses in error.
In one example he mischaracterizes Mitt Romney's role in signing a law that charges $300 per employer annually to fund health insurance for all in Massachusetts. The $300 fee was passed OVER Romney's line item veto. The main part of the bill is a punitive mandate that requires all taxpayers* acquire health insurance. Those who don't face monthly penalties enforced by Massachusetts' version of the IRS. The MA health insurance law funding comes in part from the $300 fee but mostly from shifting uncompensated healthcare funds to subsidizing premiums for poor and lower wage workers. The Massachusetts law does little to contain the soaring costs of the commonwealth's pet industry.
This kind of glossing is what troubles me about this otherwise interesting and provocative book. Kotlikoff is hardly naive about the economic and political realities facing his proposal. Libertarians don't like government programs. Healthcare professionals feel entitled to unlimited compensation. Patients want the best healthcare others' money can buy. Hospitals love their high tech profit centers. Then there are the miriad of big and small suppliers that profit from over priced products, waste and techno-churn.
America's healthcare problem is not the lack of universal healthcare. It's the lack of universal fairness in health insurance. Employer ensured workers, especially high income professionals, have their premiums paid. But they pay no taxes on this imputed income. An uninsured taxpayer showing up at the hospital had better have a bunch of high balance credit cards and be prepared for bankruptsy. Yet his taxes compensate for the lower taxes of his fortunate and better paid neighber. Kotlikoff would do away with this asymmetry and use the 'higher taxation' to help fund his scheme. One could expect Republicans to rail agaist this while Democrats knee-jerk against vouchers. He also suggests savings and thus funding could be found in reducing administrative costs in the healthcare system. Good luck on reducing hospital fat and red tape. One other loose end in Kotlikoff's plan is where do the insurer's profits go? Shareholders? High CEO pay? Into lower premiums?
Notwithstanding its holes and loose ends Kotlikoff has made a provocative case that is a must read piece of food for thought. Regardless what you think of his proposed fix, Kotlikoff is right about one thing ... Our profligate healthcare industrial complex is threatening our fiscal future.* In Massachusetts a young tax cheat can earn buy one of the special subsidized young person's
policies which doesn't require proof of income.


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