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Arnold S. Relman says our current health care system is in critical condition ("The Health of Nations," March 7). Unfortunately, his article failed in both its diagnosis and its prescription. He critiques the deficiencies in our system but proposes a utopian solution that could never exist. Although his model has been attempted and is currently in place in Canada, he neglects to examine its real world results.

In Canada, my home country, patients must wait months for procedures that are available in days in the United States, thanks to Canada's single-payer system. It may save the government money, but it costs patients plenty in pain, suffering, and anguish. If Relman is correct and "uncontrollable costs are the primary problem in our present system," then his proposal to put a huge government bureaucracy in charge of collecting taxes and allocating resources is not the answer. The solution is to move away from third-party payers and toward more individual responsibility for health care. This is the real promise of consumer-directed health care arrangements and why they will, over time, be adopted and embraced by Americans and their employers.
Sally C. Pipes
President and CEO
Pacific Research Institute
San Francisco, California

I applaud Relman for reminding us how badly our health care system needs reform. And I agree with him that our current system costs too much and provides too little in return. But Relman's analysis of the problem is self-serving. For example, sorely missing from his analysis is the enormous amount of paperwork required by payers (bureaucracy), the Food and Drug Administration's role in raising prescription drug prices (excessive regulation), the American Medical Association's monopoly on labor supply, and the exorbitant cost of medical malpractice insurance (runaway tort system). The Harvard Business School's Michael Porter argues that the real problem is competition that focuses on cost, not outcome. I believe health care is fundamentally an economic decision. If patients had information on treatment options, prices, and outcomes (quality)--at both a systemic and physician level--and if patients were free to choose any doctor, the system would deliver high-quality care at low cost. We need to shift the basis of competition, not replace it with central planning. This is not to suggest that providing care to the poor is unimportant, only that it is a separate issue.
Steve Dawson
Londonderry, New Hampshire

I have been a provider in the health care system for 30 years. I agree with Relman's analysis of the way resources are currently misapplied, but his solution doesn't address the problem of implementation. He promotes a cap on spending without showing how this will be sold to the public. I don't think consumers are ready to hear the "R" word (rationing) in relation to their own health care. And the medical-industrial complex has always been ready to exploit this fear of denial of access or services to defeat reform. Do any of our current politicians have the credibility or courage to try to educate the public about the fact that we have no choice but to reduce the growth in health care costs?
Bernard Larner, MD, PhD
Orinda, California

Relman's trenchant analysis of the health care system cites critiques that are uncannily similar to those made of the public education system. Both fields are being vigorously promoted as ideal candidates for an open marketplace to cure their respective ills. In education, this approach takes the form of competition among providers of various curricula, advertising based on standardized test scores, and parental choice of schools. What is downplayed throughout the campaign to commercialize medicine and education is that practitioners in the two professions will be forced to abandon the service ethic that undergirds their decisions to become healers and educators in the first place. The brave new world of economics will also assure that those most in need of quality medical care and quality schooling will be precisely those least likely to receive them.
Walt Gardner
Los Angeles, California


If Sally C. Pipes really believes that the reformed health care system I propose "has been attempted and is currently in place in Canada," then she hasn't read my article carefully enough or, despite her nationality, she doesn't understand Canada's problems. I didn't mention Canada, but she should know that it devotes much less of its national economy to health care than the United States. If it spent as much as we do, Canada's waiting lists could be eliminated and there would be much less public complaint. I don't propose to reduce U.S. health expenditures to the Canadian level, but rather to reform the U.S. health insurance and delivery systems to make better use of the money we already spend. Another huge difference between my proposal and Canada's system is that I advocate the elimination of fee-for-service payment and the encouragement of capitated group practice, whereas Canada still mainly relies on fee-for-service payments to doctors in private practice. The kind of "consumer-directed" health care Pipes favors is a mirage, doomed to fail. My proposed solution may not be nearly as "utopian" as her blind faith in the magic of markets, because I am proposing changes that would in principle work and could produce a socially desirable result. There is no evidence to support similar claims for market-driven health care.

Steve Dawson also believes "health care is fundamentally an economic decision" and shares Pipes's faith in the market. I argue that markets can't--and don't--work in health care and that our present problems are the result of this misplaced faith. His assertions to the contrary don't deal with my arguments, and many of his factual claims are simply wrong. Private, investor-owned insurance plans have far higher overhead and administrative costs than government plans; high drug prices are not due to the FDA's regulations but to the drug companies that set the prices; the AMA has nothing like a "monopoly over labor supply"; and the cost of our tort system is a very small fraction of the total cost of health care. Lastly, he can't set aside "providing care to the poor" as "a separate issue." It is one of the important goals of any decent health care system, and we must recognize that market forces won't get us there.

I agree with Bernard Larner that the reforms I suggest would be difficult to implement--but, as I say, they are not impossible. I do not agree that rationing needs to be an initial part of the plan, if we mean by that term the withholding, for financial reasons, of services generally acknowledged to be medically justified. The reforms I suggest would enable us to provide all medically appropriate services without spending more than we do now.


Many thanks to Jonathan Cohn for raising the problem of absent fathers in the current wave of hand-wringing about the plight of uppermiddle-class mothers ("Career Fair," March 14). In my own family, I'm the primary breadwinner, while my husband stays home with our toddler daughter. There are many reasons for this, not limited to my more lucrative career, his exceptional teaching and caregiving talents, our desire to have our daughter know us as individuals rather than as gender stereotypes, and my greater professional ambitions. We face the realization that we can't have it all every month at bill-paying time, if having it all includes the double-income comforts we previously enjoyed. Like Cohn, I am struck by how infrequently these trade-offs are cast as family decisions, rather than mothers' decisions, in the popular press and in academic debates. Cohn wonders if the preoccupation with mothering doesn't conveniently let men off the hook from considering their own choices. I would add that there appear to be many privileged women who find solace during baby's nap time in a nice cup of jasmine tea and a therapeutic read about the plight of mothers who would have been CEOs had they not made such an important sacrifice for their children.
Joselyn Zivin
Chicago, Illinois