The Health Care Mess: How We Got Into It and What It Will Take to Get Out

It would be difficult to think of two individuals who have had more extensive experience both inside and outside of the “sausage factory” of health care policy than Julius Richmond, M.D., and Rashi Fein, Ph.D. A physician and economist, respectively, both have extensive roles as government officials and advisors and are currently on the faculty at Harvard. Dr. Richmond was one of the founders of Head Start and served as Surgeon General in the Carter administration. As a Robert Wood Johnson Clinical Scholar, I initially met him through our mutual involvement in Roslyn Carter’s President’s Commission on Mental Health. Dr. Fein served as staff on President Kennedy’s Council of Economic Advisors and as an advisor to Senator Edward Kennedy. Ironically, for an economist, he also coined one of my favorite health policy metaphors: the “James Barrie theory of health care,” i.e., whenever one uses the term “consumer” for patient and “provider” for physician or nurse, “an angel dies” (1) .

Richmond and Fein, two wise experts, provide a succinct, readable history of the development of health policy and the American health care system (although they acknowledge that a letter addressed to the head of the American health care system would end up in the dead-letter department of the U.S. Post Office) over the last 60 or so years. The story they tell is premised on the notion that an awareness of history will usefully inform strategies to get us out of the mess that we are in. The story has bad guys (e.g., the American Medical Association [which did not learn from history] and, surprisingly, President Clinton) and good guys (e.g., the Association of American Medical Colleges and, surprisingly, President Nixon [who promoted health maintenance organizations and a plan for catastrophic health insurance]). The authors conclude with a somewhat broadly drawn proposal for universal health care, which they claim reflects a balance of good health policy, practical political reality, and painful lessons from history.

Overall, this is a terrific primer on health policy that I would suggest as background reading for students interested in health policy issues and for people generally seeking a better understanding of why our health care system is such a mess. The authors touch upon physician shortages, the growth of the for-profit sector, the medical-industrial complex, the roles of Congress and the executive branch, and many other critical issues at a depth that is just about right for a health care professional who is not a health policy expert.

I do, however, have a few minor concerns about the book. Given the extensive experiences of the authors at the inner circle of health policy, readers would expect to be entertained with interesting anecdotes reflecting the colorful personalities who have played a role in this ongoing national drama. It turns out that there are hardly any such stories or personality profiles. In addition, the prescription offered by the authors (which involves a public/private national health plan modeled on the Federal Employees Health Benefit Program and sold as “Medicare for all”) is presented in strokes so broad it is hard to decipher exactly what is being proposed. Further, in their efforts to preserve a role for private health plans, their proposal sounds a bit like the disastrous Medicare Part D political gerrymander. While this might imply that the authors themselves did not learn from history, the book, which was published in 2005, may have been written prior to the Medicare Part D debacle.

The bottom line is that The Health Care Mess reflects quite closely the kind of daylong conversation in which I would hope that Richmond and Fein would engage the next president of the United States.