Wednesday, July 22, 2009

A Good Book--US/UK

A book that I have used several times in my comparative health care systems class at Duke is Can We Say No: The Challenge of Rationing Health Care. Washington, DC: Brookings, 2005. by Henry J. Aaron and William B. Schwartz with Melissa Cox. It is a book length comparison of the US and UK Health Care Systems that does a good job of looking not only at health policies, but placing them in the cultural context of each nation.

I quarrel a bit with their definition of rationing (denial of care that has benefits to someone willing to pay for it) and would say that rationing is anything other than everyone getting whatever they want. But, this is a very good book.

Also, there recommendation for the U.S. health system (and any system).
1. cover all persons
2. encourage care where benefits > costs
3. discourage care where benefits < costs

Update: My good friend, and economist Marc Bellemare, writes thusly:

Greetings from the ATL. Their definition of rationing is right -- it's when price is set at lower than market-clearing price, so Q_d exceeds Q_s. That is the economic definition of rationing (as in the credit rationing literature, Stiglitz and Weiss, AER 1981.) Your definition allows for people not getting their needs/wants met, but that is everyone in a world of limited resources/unlimited needs/wants (I think that was the definition of economics Lord Robbins' had come up with...)

Just to be clear, I wasn't saying Henry Aaron doesn't know economics, just that I think in the way rationing is used culturally (as the ultimate health care boogey-man) that it is imoprtant to note that all things of value are scarce, and we decide all the time that some people get more of something than others, in a vareity of ways, typically markets. To reiterate, this is a great book.


  1. When you talk of rationing, who makes the decision. What if your mom is 85 years old, has a stroke and goes to the hospital. They say that it is doubtful she will ever be able to walk again. They decide no care is needed except to keep her comfortable.
    Well, that happened to my Mom, and she walks, 6 months later.

  2. A good question. One of my research areas is the cost of Alzheimer's disease to Medicare and how having AD affects how other diseases (like a stroke, or heart attack or cancer) are treated. What we find is that costs rise around the time of a diagnosis of dementia...but after several years with dementia they actually drop lower than average. Big question is who decided? could be living will, could be family, could be docs doing it implicitly. Can't tell from studies I have done. So, there are three possible actors: (1)person (2) family (3)providers. They all act now. I think we need to add a bit more guidance as well...there are some things being done with very small or no benefit, in some cases we don't know if there is benefit, and in others we know and don't use what we know. Friday's column touches on this a bit...I think a base closing type commission should take a comprehensive look at Medicare and at least beging to have a way to ask the question 'is this worth it'? for certain types of care.