Customer Reviews

Critical: What We Can Do About the Health-Care Crisis

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Why is Tom Daschle (who interestingly is not a physician, but a lawyer, politician, and lobbyist) in charge of the health care arena in the first place? It's insulting to us physicians that the president elect couldn't find one of the many talented physician leaders to head up this project.

With that said, Daschle's main ideas gleamed from reading the book are:

1) Set up a Federal Health Board to regulate policy and provide evidence-based practices - The idea of a Federal Health Reserve is a good one. It would allow a nonjudgmental board to improve medical care at the federal policy level without political biases.

2) Expand Medicaid - This, although reasonable, is scary. Medicaid is amongst the lowest of all reimbursers. Many treatments and procedures simply cannot be done at the Medicaid reimbursement level, such that major academic centers with Federal support eat the costs of doing business with these patients. Any expansion will have to see reimbursement rates dramatically increased or physicians protesting.

3) Mandate by law (like in Massachusetts) that individuals have insurance - This seems like a good way to increase "insured individuals." What it does for quality of care remains to be proven.

4) Pay physicians based on their success - This is a slippery slope as it will reward physicians who are less apt to take risk. Also, deciding upon which outcome measures and variables to reward will be no easy task - the scientific community has only defined the variables for a very small subset of patient care items to date.

5) Open up the federal health insurance "group policy' to all employers and individuals to obtain an economy of scale - I don't know anyone with this insurance, but it seems like a fine idea.

6) Implement an electronic medical record - this is already being implemented around the nation. The best idea would be to implement one or a few that all interact, but that would take serious organization, time, and money.

7) Criticize the US health care system as mediocre at best - There is no one best way to measure health care systems. Proxy measures such as life expectancy and infant mortality do exist, but they are confounded by different demographics in different countries, different genetic susceptibilities, different risk taking activities by health care systems, etc. The US health care system has driven most of the critical advances in health and for sure health care education in the last century and it is where many international diplomats, athletes, etc. receive their care. The real issue at hand is the massive amount of money being wasted in the system.


Interestingly, Daschle does not comment upon:
1) Malpractice claims and the cost of malpractice insurance
2) Insurance agencies and their lack of regulation and the fact that they do nothing for the system but put money in their own pockets

Any future system in the US should satisfy 3 basic groups:

1) The patients
2) The caregivers (Physicians, etc.)
3) The facilities (Hospitals, etc.)

There is no reason why lawyers, insurers, politicians, lobbyists, etc. should benefit from the system more than those crucial to it's existence.

A big part of me resisted the idea of buying a book on health care written by a former Senator. It just seemed way too wonkish for me. But I am into politics and a minute does not go by without a candidate screaming about "Health Care" and "Universal Health Care" so I figured I should get up to speed on what the debate is all about.

I'm really glad I did. In truth, Critical is a well written book and is quite interesting. Daschle cogently explains why our current health care system is broken and why there is, in fact, a desperate need to fix it. I'd heard that said many times before but did not understand why. Now I do, thanks to this book.

I am a strong believer in the free market as the best means for providing most of the goods that people want at the best price. But I now have to admit that the free market is not working when it comes to health care. It really isn't. And I am not saying this as a Democrat. I am a registered Republican.

For those who might think that this book is nothing but a left-wing, socialist rant, they would be wrong. In fact, many of Daschle's recommendations for "fixing" the system are to make our system work the way it would in a true free market environment. That is, to provide the highest quality care at the least cost to the consumer. It was really eye-opening to learn how very far away from this ideal our current system is.

Daschle's book covers most of the bases. It describes our current system and why it is so flawed (the number one cause for bankruptcy in our country cannot be called a good system of health care!) He then describes the history of trying to create a better health care system in our country, starting with Truman, up to Clinton, and on up to the current day. He outlines the players who consistently get in the way of needed reform. And, finally, he puts forward his own idea of how we might create a viable health care system that affordably takes care of people when they fall into disease.

I got a great deal out of this book. For one, I've learned that right wing talk radio is REALLY clouding the issue when they talk about health care, and is doing the country a great disservice. Daschle persuaded me on a lot of important points and made me aware of the nature of the problem. I thank him for the time he put into writing such an informative, readable book on such an important issue. If you want to educate yourself on the state of our health care system, this is the place to start.

I avoided learning about the politics of the mid-East for a long, long time. Too complex and insoluble. Then 9/11 and, well... I picked up "The Mid-East for Dummies" at Barnes and Noble. "It's a start," I told myself, and not a bad one as it turns out.

As a supposedly responsible political actor, I've found myself similarly ignorant when it comes to the droning debate on health care. And, God knows, listening to the candidates for President is not terribly edifying in this regard. "Tastes great, less filling" would pass nicely for substance on this (or almost any other) topic in this election season.

To my rescue rides Tom Daschle and his co-authors whose "Critical: What Can We Do About the Health Care Crisis" could have just as well been sub-titled "U.S. Health Care Policy for Dummies."

Unlike the "Dummies" books, this one is prescriptive. Senator Daschle et al bascically argue that the U.S. Congress is in over its head on health care and--like it did on monetary policy with the creation of the Federal Reserve in 1913--should outsource its decision making on the immensely complex topic to a Presidentially appointed panel of experts. This is a an interesting proposition, coming as it does from the former Senate Majority leader who hails from a state with deep populist roots. But the case he makes is not uncompelling.

Daschle calmly traces how health care reform has crashed repeatedly upon the same special interest shoals, at least since the Depression. The shape of the barely submerged obstacle may change (doctors, unions, insurance companies), but its sheer, hulking mass only increaseth. Congress, he argues, has neither knowledge nor institutional will to make good and far-sighted decisions on behalf of its constituents.

The book is worthwhile if for nothing other than its mid-section, wich recounts the history of attempted reform, especially since Truman. The Clinton/Magaziner effort of the early 90s gets special attention, as it should. Daschle--ever the statesman--manages to scoff at how on-its-face silly was the C-M approach to health care reform, while not laying a glove on the former first lady. In fact, his account is practically tantamount to hagiography compared to the version delivered by Carl Bernstein in his biography of Mrs. Clinton.

Again, this is a very helpful book for the lay reader. But its brevity and accessibiltiy require that many good questions are left open. Is the obsession over absolutely universal coverage necessary? If the fault of the Clinton plan was primarily that it was too detailed, what details could have been eliminated with eviscerating its substance? If Congress can't handle health care, what else should devolve from its purview? Energy policy? The more delicate pieces of foreign policy oversight?

And finally, the elephant which has taken up tenancy in Daschle's rather modestly sized room: "gee, this all seems pretty expensive, doesn't it?" By book's end, I found myself with the mental image of one dial spinning clockwise, tallying the cost of the incremental (and undoubtedly worthwhile) programs Daschle proposes. Another opposing dial spun the opposite direction, counting the result of the cost savings the book proposes. You can guess which one spins faster.

Three things become quite evident in reading "Critical." The first is that tackling the challenge of universal health care coverage will requre monuumental Presidential leadership, and an almost reckless risk of political capital which no event other than a fresh election will generate. Clinton promised a proposal in the first 100 days of his presidency. And while that turned out to be a hyperbolic mistake of ambition, it nonetheless reminds us that in order for health care reform to succeed, it likely must be a new President's top priority.

Second, although Daschle's proposal of a National Health Board is not new, its timing may be apt. Health care has bubbled to the top of the list of main street issues, and Congress has perhaps never in the modern era been less trusted to address cleave the Gordian knot.

And finally, you can bet that if the nation chooses Barack Obama as its 44th President, this is not the last we've heard from Tom Daschle on health care.

Probably not a bad thing.

Daschle, having just been named Secretary of HHS, will be a major voice in the reformation of our health care system. While his book does not really address adequate methods for controlling costs, it does posit a potential method for organization---a Federal Health Board modelled on the Federal Reserve. He also proposes a way to expand coverage by using an existing insurance plan---the Federal Employees' Health Plan. I would highly recommend this book as well as Ezekiel Emmanuel's (Rahm's brother) "Healthcare Guaranteed" to readers wanting to anticipate what the Obama administration may be proposing.

The U.S. is the only industrialized nation without universal healthcare. Universal healthcare has been fought by special-interests since at least 1945 when Harry Truman tried to implement it. Daschle recognizes that the power of political forces involved make Congressional involvement in any details fatal to its success. Thus, in "Critical" he proposes a Federal Health Board, modeled after the Federal Reserve Board, to manage a U.S. version.

The board would be composed of independent experts insulated from politics. Shifting to a more effective drug or service would be accomplished without an act of Congress or White House political support.

"Critical" also summarizes where we are in healthcare. We spend 50% more/person than the next most expensive country (Switzerland), and more than twice the industrial world's average. Between 2000 and 2007, U.S. health insurance premiums rose 98%, while wages increased only 23%. Those incurring serious medical problems are likely to lose their jobs and associated health coverage; even brief lapses in coverage may be ruinous.

Proliferation of direct-to-consumer advertising has fueled patient demand. The costs of drugs, hospitals, and doctor visits in higher in the U.S., as well as administrative costs (31% in the U.S., vs. 17% in Canada; 3X that of the most effective nations - France and Japan).

Those without insurance are charged far more than those with coverage. Export companies are at a disadvantage, burdened by high healthcare benefit costs. In 42 states, poor adults without dependents never qualify for Medicaid. The Institute of Medicine estimates that lack of health insurance leads to 18,000 extra deaths/year. High deductibles creates another problem.

U.S. infant mortality is 28th in the world; blacks have a mortality rate 2.5X of whites.

Potential savings, per Daschle, include use of electronic medical records, promoting evidence-based medicine, reduced administrative costs, and increased emphasis on prevention.

I had high hopes for this book. Except for the one innovative idea, the creation of a Federal Health Board, this was an average book compared to the many available which detail the challenges of our dysfunctional healthcare system far better. The book is an easy read, doesn't cover much in depth, but highlights all of the key points one needs to know to speak intelligently about the healthcare system (and presumably to be Secretary of Health and Human Services).

It is unclear whether creation of a Federal Health Board will be able to provide the impetus needed to make the American healthcare system higher quality, less costly, and more inclusive with universal coverage. One thing is clear from his book and that is Americans want a better healthcare system than currently exists. It won't be a pure single payer government run system. It won't be a free market private industry program. It will be a hybrid. What type of hybrid? Time will tell.

The book is divided into five parts. Part One details the healthcare system in crisis filled with individual anecdotes on how it has bankrupted, failed, and at times killed people without adequate insurance coverage or financial means to pay for care.

Part Two talks about the history of healthcare reform, which covers the beginning of the twentieth century. It highlights efforts by President Truman, Medicare and Medicaid legislation, as well as attempts in the 1970s, 1980s, and the early 1990s.

In Part Three, Daschle looks at why reform hasn't occurred. He begins to build his case for creating a new entity, a Federal Health Board, which is modeled after the Federal Reserve as well as the British National Institute for Health and Clinical Excellence (NICE).

Part Four he focuses in on how the Federal Health Board would be structured (a central board with several regional boards). As an independent body, it would recommend that only medications, treatments, and procedures backed by medical evidence and not by marketing be covered under government run insurance plans. It would also determine what criteria and benefits private insurers must offer to participate in expansion of the FEHBP (Federal Employees Health Benefits Plan). This new market would insure those unable to get employer-based or government run insurance programs currently.

Finally in Part Five, he makes the case on the likelihood for healthcare reform.

The best part of the book is Senator Daschle's perspective on the healthcare reform attempt by the Clinton administration, particularly how excitement and momentum moved the country towards reform only to see external events, special interest groups, as well as political missteps, caused it to die. Without a doubt, future leaders who hope to forward any healthcare reform package would best learn what not what to do.

A better book and fascinating read about how dysfunctional our healthcare system (and he quotes the book) is Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. Another book which can help you navigate the healthcare system is the insider's guide Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System.

Here is a flavor of campaign book I didn't previously know existed. Sen. Daschle is not running for an elected office, but seems now to have attained the goal behind the book - Secretary of Health and Human Services, and White House go-to guy for healthcare reform. The book gains a great deal of importance because of these recent appointments.

I assume that co-author Lambrew did much of the detailed research and that co-author Greenberger did much of the writing, but it's Daschle's tone and manifesto that come through. Those looking for literary eloquence or scholarly dispassion will want to go elsewhere. The book is a must-read for anybody who cares more than superficially how the healthcare debates of 2009 might play out.

That said, the history of healthcare policy and its side excursions in the United States is well covered, though others might be less gentle towards the Clintons on their 1993 fiasco. (At the time the book was written, she could well have become the Democratic nominee.) Also, bearing in mind that the book was written prior to the current economic miseries, many of the points he makes about the consequences of lack of universal coverage are now even more compelling. The evolutionary history of the Federal Reserve Board, the model for Daschle's central proposal, is also enlightening.

So, can we establish policy around healthcare through an apolitical board of experts that is as effective as our ways of dealing with monetary supply, or air traffic safety, or military base closings? Only time will tell. But, if so, this book will be seen as the beacon that helped chart the course.

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Addendum August 2011

For the record, although I doubt that many will see this. The original review was written between the time that Daschle was nominated for HHS (Obama's first cabinet appointment) and the time he had to withdraw due to personal financial irregularities. Given what has subsequently unfolded, this now seems a real tragedy. Could he have charted the course for a better bill than was achieved? One must think almost certainly, as almost everybody -- pro and con -- agrees that there is much room for improvement.

We've got plenty of political tragedies to contemplate today; here, for the historians, is perhaps a smaller-scale one but with long-term repurcussions.

A thoughtful considerate book on an important subject that goes beyond the typical tired paranoid delusions by the right that health care with some government regulation and coordination will lead to socialism. The book simply puts forth the pressing need to discuss and plan a comprehensive approach to this issue which by any measure is better than the old tired way this issue has been handled since the Reagan administration.

This book is sound in its review of the history and science of need and opportunity for health care reform. While our new Secretary of HHS,former Senator Tom Daschle knows how to relate to congress to get needed changes, this book shows he has a great fundamental approach to the use of government leadership as well as market forces to assure affordable and effective health care for all Americans.

I have worked for almost thirty years to help the "marketplace" work in health care. This includes a ten-year stint in Detroit with the Auto Companies and UAW working for health care change. There is no way the market by itself can bring needed reforms. Senator Daschle provides a strong leadership perspective on how to combine the forces of market and government as relates to health care. This book practical,and clear in its message. It is highly recomended for anyone interested in health care and reform.
James. B. Kenney, Ph.D.

Unfortunately, this book gets inspiration for its answers from Western Europe, particularly the UK. But the author seems unaware that the UK already has lower cancer survival rates than the US, higher waiting times than the US, less mri and cat scan machines per person than the US, less alternative treatment and second opinion options than the US, and less available dental care (and worse looking teeth) than the US.

The only thing the UK has better than the US is overall life expectancy, but that is more due to US roads, crime, and diet than healthcare quality.

If we follow the prescriptions in this book, we will have a sicker healthcare system, not a healthier one.