Front Cover

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Title Page, Copyright

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Contents

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p. v

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Foreword

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pp. vii-viii

Of all the challenges facing the United States, one of the most daunting and important is the growing inadequacy of our national health care system. Sound analysis of the problem and constructive recommendations on the solution—or, as my colleague Hank Aaron would put it, accurate diagnosis combined with effective prescriptions—is a major institutional commitment of the Brookings Institution. We’re lucky to have had Hank on our...

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Acknowledgments

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pp. xi-xii

I owe thanks to many people who have contributed to this volume. Melissa Cox began as a research assistant for this project but became a coauthor thanks to her pervasive contributions based on intimate knowledge of British institutions and sources, as well as her energy, indefatigability, and intelligence. Alan Garber, Barbara McNeil, Joseph Newhouse, and a fourth referee reviewed the entire manuscript...

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Chapter One: The Promise and the Problem

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pp. 1-10

I owe thanks to many people who have contributed to this volume. Melissa Cox began as a research assistant for this project but became a coauthor thanks to her pervasive contributions based on intimate knowledge of British institutions and sources, as well as her energy, indefatigability, and intelligence. Alan Garber, Barbara McNeil, Joseph Newhouse, and a fourth referee reviewed the entire manuscript...

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Chapter Two: The British System

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pp. 11-29

In a famous exchange, Ernest Hemingway wryly responded to F. Scott Fitzgerald’s observation that “the rich are different from you and me” by saying, “Yes, they have more money.” In comparing the American and British health care systems, a Fitzgerald-like comment would be that the health systems of the two nations differ because of history, politics, and medical institutions. A Hemingway-like response would be that Americans...

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Chapter Three: Matters of Life and Death

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pp. 30-58

New ways to prevent death constitute some of the most spectacular and costly advances in health care: —Death from chronic, severe kidney failure was sure and swift until machines were invented that could replace many of the excretory functions of the kidney and ways were found to prevent or slow the failure of kidney transplants. —Victims of hemophilia, the bleeding disease linked in history texts to royalty, could not be effectively treated until the key blood constituents that produce normal clotting...

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Chapter Four: Quality of Life

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pp. 59-76

Tight budgets, one might think, would more severely limit care that “merely” improves the quality of life than care that saves lives. The story is a good deal more complicated, however. Discomfort may be acute, unremitting, and disabling, or it may be merely annoying and inconvenient. The benefits of surgery providing artificial hips that return bedridden and pain-racked invalids to pain-free mobility are at least as great as the gain from...

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Chapter Five: Diagnoses

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pp. 77-92

Patients are sometimes comforted by the myth that physicians are inerrant, a delusion some unkind medical critics allege that physicians welcome. This belief that physicians seldom err has certain advantages: it increases patients’ willingness to adhere to prescribed regimens, and it alleviates anxieties that can obstruct recovery. But as all competent doctors and well-informed patients realize, it is false. In fact, physicians are usually at least a bit unsure about the precise cause of various signs and symptoms, as well...

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Chapter Six: Rationing and Efficiency

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pp. 93-107

Health care rationing can be done efficiently or inefficiently. This chapter explains the principles that must apply to ensure that whatever is spent on health care yields the largest possible overall benefits. Chapter 8 will raise questions about whether the U.S. political and health care systems are well designed to achieve this outcome. Some Basic Principles People are usually assumed to spend their incomes to get as much satisfaction from them as possible. In the jargon of economics, free consumer choice is assumed to be “efficient...

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Chapter Seven: Efficiency and Inefficiency in British Health Care

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pp. 108-130

Efficiency in the use of medical resources requires that all care not provided be less valuable than any care that is provided.1 No medical system passes this test. Every country, even those in which services are severely rationed, wastes some resources because of correctable clinical errors that misdirect services to patients who are unlikely to benefit from them. But the evidence reported here confirms that the British system fails the test of efficiency in another sense. While some services are provided up to or near the...

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Chapter Eight: Rationing Health Care in the United States

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pp. 131-148

Many Americans find unthinkable the idea that the United States might one day ration medical care. The fact that millions are entirely uninsured or lack adequate coverage is widely accepted, if regretted. However, in a strange exercise in mental compartmentalization, limits on care for those with good health insurance or enough money to pay seem strange and unthinkable. Yet continuation of past rates of growth in health...

Appendix: Frequency of Surgery

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pp. 149-154

Notes

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pp. 155-194

Index

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pp. 195-203