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Critical Condition: How Health Care in America Became Big Business--and Bad Medicine Paperback – October 11, 2005

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Editorial Reviews

From Publishers Weekly

Bestselling investigative journalists Barlett and Steele (America: What Went Wrong?) deliver a devastating indictment, supported by excellent research, of a health-care system that they say is failing to provide first-rate services to its citizens, 44 million of whom are without insurance. According to these Pulitzer Prize–winning reporters, now with Time magazine, the U.S. compares poorly with other Westernized nations in delivering quality care and a healthy life expectancy, and preventing infant mortality. Per capita health-care spending continues to exceed the amount spent by many other countries, the authors say, because one out of every three U.S. dollars pays for administrative costs. The authors also present case histories of patients, some with life-threatening conditions, who were ignored by bureaucratic HMOs that put profit first. Barlett and Steele describe how health care first became driven by profits on Wall Street during the Reagan administration. Competing insurance plans, they say, led not to better choices for consumers, but to physicians who are prevented by insurers from prescribing needed treatments; a severe shortage of nurses; and unsafe hospitals where staff shortages and unsanitary conditions result from cost-cutting. The authors, who strongly advocate a single payer plan, successfully depict a health-care system in crisis.
Copyright © Reed Business Information, a division of Reed Elsevier Inc. All rights reserved. --This text refers to the Hardcover edition.

From The New England Journal of Medicine

Love thy neighbor: an American paradox? The United States has one of the highest levels of church attendance in the world, but when it comes to health care, it seems that churchgoers find it difficult to love their neighbors in the way that secular Europeans take for granted. Critical Condition, a fine polemic, describes how health care in the United States is financially rewarding to insurers and providers but delivers poor-quality health care to many of its citizens. Although U.S. health care has been described as the "best system in the world" (and it is in parts), it is also a failure because of its inability to deliver good-quality care to the disadvantaged. However, this paradox is also the triumph of the system, since its component parts do what they are designed to do. Medicaid provides variable support for some of the poor. Medicare offers a finite package of care for the elderly, with patients in the eastern United States receiving 60 percent more care than those in the West. Veterans are cared for in a mini-National Health Service, which appears to have had some success in shifting cases from the hospital to primary care settings. The majority of U.S. workers are offered little choice in insurance plans by their employers, who, confronted by an escalation in costs, increasingly have recourse to higher levels of deductibles and copayments and are pruning benefit packages. Then there are the 43 million Americans with no health insurance. Over the life cycle, the American lottery can move people across these systems with significant consequences for their material well-being and health. In each of these health care systems, Americans face price discrimination and bankruptcy if they are unlucky in their genes and life events. In their book, Barlett and Steele describe these problems in graphic detail. They explain how, instead of cross-subsidizing the poor with revenues from people who are more affluent, providers charge them higher prices for the same services as those received by the more fortunate. This price discrimination is supported by vigorous pursuit of people who fail to pay their health care debts. American private-sector bureaucrats, like their public-sector counterparts in Europe, increasingly have recourse to "cookbook medicine," in which practice guidelines and protocols (all too often evidence-free) are imposed on practitioners. Given that medical practice exhibits established and significant variations and well-chronicled medical errors, together with a remarkable reluctance to measure success in improving the quality of life of patients, it is unsurprising that bureaucrats seek to establish quality standards in the health care industry. What is surprising is that their efforts in the United States and elsewhere remain feeble and are rarely "confused" by evidence of cost-effectiveness. But there again, this is no accident but, rather, the deliberate product of the incentive structures inherent in the U.S. health care system. These incentives protect the insurers and providers from contestability, muting price competition and ensuring that competition in quality is superficial and rarely informed by patient-outcome data. Barlett and Steele offer a nicely documented and well-written insight into all that is bad with the U.S. health care system. For skeptical Europeans on the receiving end of evidence-free health care reforms often inspired by unevaluated policies from the United States, this book is a welcome antidote. There are no simple solutions to complex problems inherent in health care systems worldwide, and the authors' advocacy of national insurance as the solution to the problems of equity and access that they document is unconvincing. First, insurers and providers thrive at the current health care feast and are unlikely to support reforms that redistribute their jobs and incomes. Second, tax-financed national insurance does not address the problems of inefficiency in the supply of health care as demonstrated by Europe. National insurance enables societies to love their neighbors, but as Adam Smith, the 18th-century Scottish economist, noted, capitalists always conspire to exploit the consumer, and nowhere is this more evident than in the health care sector. Will Barlett and Steele precipitate altruistic reform, unlike their many predecessors who have described the failings of U.S. health care? The recent presidential election makes this unlikely. Americans appear to prefer to practice their religion in isolation from their social policies. Alan K. Maynard
Copyright © 2005 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS. --This text refers to the Hardcover edition.

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Product Details

  • Paperback: 288 pages
  • Publisher: Broadway Books; unknown edition (October 11, 2005)
  • Language: English
  • ISBN-10: 0767910753
  • ISBN-13: 978-0767910750
  • Product Dimensions: 5.2 x 0.6 x 8 inches
  • Shipping Weight: 7.2 ounces (View shipping rates and policies)
  • Average Customer Review: 4.2 out of 5 stars  See all reviews (38 customer reviews)
  • Amazon Best Sellers Rank: #212,562 in Books (See Top 100 in Books)

Customer Reviews

Top Customer Reviews

By M. J. Petrillo on October 15, 2004
Format: Hardcover
It's funny that in this political season there is not much attention being paid to this book. Because this is exactly what the candidates should be paying attention to. As a life long conservative I could never have imagined rating this book highly, but it speaks the truth. The authors discuss the present day health care system, and where the present "market driven" emphasis has brought us as a nation. And truthfully, as we all know, it's not good. The authors lay out simple facts that we all know, but for some reason, strike us as incredible. For example, why is it that in the richest and most powerful nation that the world has ever known, is it necessary for parents to have to hold fundraisers and garage sales to finance the medical treatments that their children need to survive. We have all seen it, but have we ever actually thought about it? That's what this book does. It makes us look at what has become ordinary in this country, and ask why? What good is it to be the richest and most powerful country on Earth, if we can't take care of our children or our parents without having to go into bankruptcy, or holding a bake sale to finance necessary medical care. This is an eyeopening book about the sad state of our health care system. Plaese read this book and think about it. What makes a country great? Is it the flag, or the military? Or is it the way a country takes care of its people? Or the way the people take care of each other. It's funny, but I always would spout out the rethoric that we had the best health care on earth, but this book made me think. Do we? And I think we all know the answer; no. And why don't we? We should, shouldn't we?
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Format: Hardcover
For those people who vaguely remember when healthcare & insurance was generally a manageable aspect of our lives (as opposed to being a source of stress & potential financial ruin), this book will explain very well how healthcare in US arrived at the point where it is today. For younger readers, this book will remind them that once upon a time, there was a country where insurance was fairly comprehensive & affordable, hospitals were oriented towards community rather than being part of a bottom-line-obsessed corporation, and pharmaceutical commercials were not littering the airwaves.

The authors do an excellent job of showing that the shift, on every level of healthcare, to a market-based economic model has achieved exactly the opposite of what the proponents of the free market claimed would happen. Instead of streamlining healthcare & making it as a whole more efficient and affordable, the shift to the free market has actually created a massive bureaucracy (which conservatives claim to loath) and a far less efficient healthcare system. Certainly it is not any more affordable. Anyone who is familiar with medical collections & with the stunning increase in bankruptcies over the last few years can attest to this. The authors underscore their arguments with a litany of horror stories of patients dying or suffering hugely at the hands of a hopelessly tangled system which emphasizes the bottom line over the welfare of the patient.

All of this is well and good, and mighty depressing. However, only a minimal amount of time is devoted to what might be done about it.
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Format: Hardcover Verified Purchase
I agree with the authors on the big picture: the state of health care in the U.S. is a scandal that should lead the news most nights. But the authors are able to describe only the tip of this iceberg, the part most exposed to the public. By this I mean that most of the book is a series of incidents along the lines of "Mr. X tried to get procedure Y but was denied for crappy reason Z." Or "HealthShysters, Inc. went under and left a million people without medical care."

I was hoping for an analysis which would examine more closely the economic and politcal roots of the current predicament. The subtitle of the book, after all, is "How Health Car in America Became Big Business and Bad Medicine"-- but I felt that precisely "how" is too often elided.

On the other hand, the current one is an easy read and a reasonable introduction to an important issue.
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Format: Hardcover
It's no secret that American healthcare has some problems. I wanted to get more background on this issue, and I discovered "Critical Condition." I found it to be readable, and it illuminated a number of healthcare crisis points. If you've ever read "The Rainmaker" by John Grisham, you'll have some idea of the stories this book contains. Free market healthcare was touted as the best possible way to ensure low prices and good treatment via competition (oddly enough, by the same guy who came up with the "body count" progress-measurement system in Vietnam.). But the authors contend it has led to higher costs, inferior care, and an uninsured class where millions are only an illness or accident away from financial ruin. And to top it off, the insurance companies have taken away patient care decision-making away from the doctors. I've seen and experienced some of the issues highlighted in "Critical Condition," and I'm appalled that a so-called "hyperpower" has a health care system where families must conduct bake sales to cover medical bills. I commend the authors for illustrating this problem in layman's terms.

However, they aren't so clear when it comes to a solution, and a couple of points stand out. First, the authors criticize efforts to speed up the introduction of new medicines. They argue that some drug companies do this to make a quick buck at the expense of patients. Perhaps they have a point, but on the other hand those with terminal cancer or AIDS have pushed for quicker drug introduction because their lives are on the line. Don't people in this category deserve to take a chance that may save them, especially if they have nothing to lose and everything to gain? Second, they argue for a standard IT system to ease the exchange of medical information.
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