In This Review

Competing Solutions: American Health Care Proposals and International Experience
Competing Solutions: American Health Care Proposals and International Experience
By Joseph White
Brookings, 1995, 392 pp.

This book addresses health care reform in the United States, after the debacle of 1994. It offers excellent critiques of the Clinton plan and its congressional alternatives, concluding that the Clinton plan attempted to combine two quite different and to some extent incompatible approaches--managed competition and what White calls the international standard. This standard is distilled from the health care systems of six other rich countries: Canada, Germany, Australia, Britain, France, and Japan. There is much diversity among these systems, and all, like the United States', are experiencing discomfiting increases in outlays. But relative to GDP, all are considerably less expensive than the U.S. system, those of Japan and Britain by more than half. And they have certain common characteristics: universal coverage, central funding (from general or payroll taxes), negotiated fee schedules for physicians, budget limits on hospital expenditures, and (usually) separate capital budgets for medical equipment.

White takes for granted that the U.S. health care system should be redistributive, not just from the well to the ill, as under any insurance scheme, but also from the rich to the poor. This normative position is more widely shared in the six foreign countries he examines than the United States. And White neglects to address how the basic benefits package is to be defined in a world of rapid technological advances, observing merely that it should exceed that of today's Medicare and would require a political judgment. But the U.S. political system has a history of extending benefits without adequate appraisal of costs, particularly when they are uncertain but likely to rise. The issue of health care reform will not go away soon, so White's discussion of the arrangements and experiences of other countries is most useful.