Flatlined: Resuscitating American Medicine

ON JUNE 1, 2009, GENERAL MOTORS DECLARED BANKruptcy. Some blame management, others blame labor. But 39% of a 2005 GM employee’s hourly wage was related to health care costs—costs that management and labor were powerless to control. Two trillion dollars a year—16.5% of the gross national product—is spent on health care in the United States. Medicare and Medicaid expenditures account for 23% of the federal budget and are increasing faster than suspected global temperatures. If trends continue, polar bears are likely to stay afloat longer than the current health care system. Expense is not the only problem. Eighty-two million nonelderly US individuals have “insufficient, unstable, or no insurance coverage” (p xii). With an abundance of raw statistics such as these, Guy Clifton is able to draw readers into his treatise on the health care conundrum. Clifton argues that the US health care system is inefficient and expensive, providing limited access and variable quality. While somewhat overambitious, Clifton’s solutions offer insight into the complexity of a system in urgent need of change. Clifton combines his bedside experience as a professor of neurosurgery with his recent exposure as the 2006-2007 Robert Wood Johnson Foundation Health Policy Fellow to offer a broad perspective on health care reform. Clear, concise, well organized, and well researched, the book could be a quick read, but the statistics are so compelling and the issues are so complex that readers will be hard-pressed not to pause to attack the margins of each page with their own comments. The 274 pages of narrative are divided into 3 parts: “Why the Uninsured Should Be Covered,” “Why Health Care Is So Expensive,” and “Reforming American Health Care.” There is no question where Clifton stands on these issues. The 22 chapters have similarly unambiguous titles, with well-placed, practical subtitles, allowing one to put down or pick up the book at a moment’s notice. Following the narrative are 37 pages of “Notes,” arranged chapter by chapter. These notes reflect Clifton’s personal involvement as a Senate staffer, with varied sources relating to testimony before US Senate committees, press releases, and commission reports. The quality of these statistical sources adds legitimacy to Clifton’s call for urgent health care reform. While Clifton’s statistics on why to cover the uninsured and why health care is so expensive may be informative and insightful, his statistics on how much US health care reform will cost and where money will come from range from an informed estimate to anyone’s best “guesstimate.” Clifton cites the article “Covering the Uninsured: How Much Will It Cost?” in Health Affairs Web Exclusive (June 4, 2003), by Hadley and Holahan, which estimates a cost of $73 to $100 billion in addition to what is already being spent on the uninsured. Clifton puts that cost at 4% to 5% of a $2 trillion health care system, a system replete with wasteful spending. How much waste? In his “30 Percent Waste—or 50?” chapter, Clifton estimates that at least $700 billion dollars is being wasted on inefficient and unnecessary health care. Accordingly, Clifton proposes a federal solution. First, cover the uninsured as well as Medicaid and State Children’s Health Insurance Program patients with a private insurance equivalent to stop the cost shifting that leads to increased premiums. Next, Clifton proposes federal regulation of insurance companies mandating that insurers provide coverage equal to that provided to federal employees and disconnecting insurance from employment, thereby creating a competitive insurance market for the 247 million individuals in the non-Medicare population. Furthermore, Clifton proposes eliminating fee-for-service care and reducing costs by bundling payments to hospitals and specialists together. Pointing out that 10% of the population accounts for 70% of health care costs and that one-fourth of Medicare spending goes to costs incurred in the last year of life, Clifton argues for better coordination of care, using the “medical home” concept. Clifton’s most ambitious proposal is the creation of an American Medical Quality System (AMQS). Modeled after the Federal Reserve, with a board in Washington and state or regional boards, the AMQS would have more responsibilities than the guardians in Plato’s Republic. The AMQS would “develop standards for the application of procedures, the treatment and prevention of diseases and workups” by funding “research to generate the missing information needed to create guidelines and protocols” (p 224). The AMQS would also evaluate the effectiveness of medical technology and make its findings public as well as make specific recommendations on payment policy to BOOK AND MEDIA REVIEWS