The Future U.S. Healthcare System: Who Will Care for the Poor and Uninsured? (Paperback)

by Stuart H. Altman (Editor), Uwe E. Reinhardt (Editor), Alexandra E. Shields (Editor)

Editorial Reviews

From The New England Journal of Medicine, June 4, 1998
There are 43 million uninsured Americans (and millions more underinsured), because the richest country in the world has yet to develop the consensus that would provide every citizen with access to an appropriate range of health care services, regardless of health status or personal income. The problem of the uninsured persists in a country that is enjoying the benefits of one of its most sustained economic expansions and where there is even the prospect of achieving a balanced budget in 1998.

The contributors to this book, one of whom is a physician, present the sobering problem of the uninsured not only as real but also as getting worse. After the 1994 failure of health care reform, a national conference sponsored by the Robert Wood Johnson Foundation was organized to provide a forum to discuss ongoing trends in health care coverage. After the conference, additional papers were solicited to present as complete a picture as possible of the problem and to offer an array of views and recommendations by some of this country's outstanding health economists and policy experts.

The book is organized in five sections. Part I presents the problem and includes a chapter asking if the medically uninsured will always be with us. Part II describes the traditional safety net, which includes health centers, public hospitals, and academic health centers and the strains these organizations are currently experiencing as they are buffeted in a rapidly changing marketplace. Part III explores the changes in hospital ownership, including both investor-owned and not-for-profit organizations. Part IV, in exploring current options for solutions, emphasizes incrementalism. This section includes chapters that present both the positive and the negative features of the increasing state role in addressing the problem. Part V explores more comprehensive solutions, concluding with a philosophical and ethical case for universal health insurance coverage.

Although there is no single chapter devoted to children, a number of the authors note that as of 1994 there were approximately 10 million uninsured children and millions more who were underinsured. As many as 3 million to 3.5 million children were eligible for Medicaid but unenrolled. Some authors come close to predicting the establishment of a program similar to the State Child Health Insurance Program (SCHIP), which was established as part of the 1997 Balanced Budget Act (Title XXI). SCHIP is an example of incrementalism and could provide health insurance for another 3 million to 5 million children. Complete Medicaid enrollment plus SCHIP will still leave 4 million to 6 million children uninsured, since in 1998 the number of uninsured children climbed to 12 million.

Some authors suggest that incrementalism is the American way and that this is perhaps the best this country can do. Since most of the authors by far are economists, readers should not be surprised that relying on incrementalism produces multiple approaches to addressing the issue of the uninsured, some of which are contradictory. The range of views offered adds to the book's value.

Medicare is also discussed in a number of the chapters. Since Medicare, even though it needs financial fine-tuning, is the closest this nation has come to universal coverage, a full discussion would have been helpful. Because of Medicare, people over the age of 65 have access to basic health services without a financial barrier, disparities in the use of health care between high- and low-income Americans have virtually been eliminated, and poverty among those over 65 has been substantially reduced.

There is no in-depth discussion of the health care work force in this book. Therefore, "Who will pay for the poor and the uninsured?" would be a more accurate reflection of the book's content than the subtitle, "Who will care for the poor and the uninsured?"

In summary, as the editors intended, this book is a timely benchmark and contribution to the understanding of why this nation alone in the developed world does not yet provide universal health care coverage. As a result, the future of U.S. health care for all, not just for the poor and uninsured, remains uncertain.

Reviewed by Joel J. Alpert, M.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

• Paperback: 426 pages
• Publisher: Health Administration Press; 1 edition (October 1997)
• Language: English
• ISBN-10: 1567930670
• ISBN-13: 978-1567930672
• Product Dimensions: 9.5 x 6.8 x 1.5 inches
• Shipping Weight: 1.6 pounds
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