Introduction to U.S. Health Policy: The Organization, Financing and Delivery of Health Care in America (review)

Which one of the two statements is correct?

1. a. The United States has the best medical system in the world.

2. b. The United States has one of the worst health care systems among the developed countries of the world.

The irony of U.S. health care is that both statements are correct, says Donald A. Barr at the very beginning of the preface of the reviewed book. For those wishing to understand how the U.S. can simultaneously have the best and the worst of health care system among industrialized countries, Donald A. Barr's Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America offers a helpful starting point.

The United States spends more on health care than any other country. Stratospheric growth of health care expenditures has been induced by technological progress, demographic changes, and changes in health needs. The total national expenditure on health care in 1970 represented 7.1% of the gross domestic product (GDP). By 2003 this figure had risen to 15.3%, which is 140% above the average for OECD (Organization for Economic Cooperation and Development) countries. Projections of the future growth in national health care expenditures point to health care consuming 18.7% of GDP by 2014 (data from Medicare and Medicaid Centers).

Despite high level of health care financing, substantial problems plague the quality of care. Health indicators for the population (such as infant mortality, avoidance of preventable mortality, and life expectancy) reveal a society that is not nearly as healthy as it could be. The World Health Organization Report of 2000 ranked the performance of the United States health system number 37 in the world (of 191 countries), sandwiched between Costa Rica and Slovenia.

From the very beginning, Barr's book is intended to inform the reader of the complex history of health care in the United States, of the many programs that have evolved to pay for and provide health care. As the book gives a broad overview of U.S. health care system, it is a good starting point for European readers with little familiarity of that system for exploring its complexities. This generally easy-to-read book can also appropriately serve as a basic text for a health policy course or in the medical or nursing school curriculum.

The author is an associate professor of both sociology and human biology at Stanford University and is the founder and director of Stanford's undergraduate health policy curriculum.

The book has 13 chapters. All chapters on specific issues conclude with a short summary. Across the chapters the author addresses topical and policy-relevant issues including the consequences of leaving people uninsured against the costs of health care, rapid escalation of technology of non-proven cost-effectiveness ratio, defensive medicine, local variations in patterns of health care, adverse selection, cream-skimming and so on—all topics too familiar to any developed health care system in the world.

In the first chapter of the book (Health, Health Care and the Market Economy) Barr describes two fundamental decisions about health care in the U.S. that set it on its present course: the decision to approach medical care as a market commodity, and the decision to grant sovereignty to the medical profession over the organization and financing of medical care. The author identifies also the three challenges that lie at the center of U.S. health policy reform: constraining the cost of care, maintaining and improving the quality of care, and increasing access to care. As the reader goes through the book, s/he learns that these are not three separate problems but three faces of a single problem. Policies that address only one of these issues will invariably affect the other two.

The core strength of this book might be the second chapter on the differences between...